Aspergillosis in immunocompromised paediatric patients: associations with building hygiene, design, and indoor air

Outbreaks of Fungal Infections in Hospitals: Epidemiology, Detection, and Management

Nosocomial clusters of fungal infections, whilst uncommon, cannot be predicted and are associated with significant morbidity and mortality. Here, we review reports of nosocomial outbreaks of invasive fungal disease to glean insight into their epidemiology, risks for infection, methods employed in outbreak detection including genomic testing to confirm the outbreak, and approaches to clinical and infection control management. Both yeasts and filamentous fungi cause outbreaks, with each having general and specific risks. The early detection and confirmation of the outbreak are essential for diagnosis, treatment of affected patients, and termination of the outbreak. Environmental sampling, including the air in mould outbreaks, for the pathogen may be indicated. The genetic analysis of epidemiologically linked isolates is strongly recommended through a sufficiently discriminatory approach such as whole genome sequencing or a method that is acceptably discriminatory for that pathogen. An analysis of both linked isolates and epidemiologically unrelated strains is required to enable genetic similarity comparisons. The management of the outbreak encompasses input from a multi-disciplinary team with epidemiological investigation and infection control measures, including screening for additional cases, patient cohorting, and strict hygiene and cleaning procedures. Automated methods for fungal infection surveillance would greatly aid earlier outbreak detection and should be a focus of research.

Seasonal variation of airborne fungal diversity and community structure in urban outdoor environments in Tianjin, China

Airborne fungi are ubiquitous in human living environments and may be a source of respiratory problems, allergies, and other health issues. A 12 months study was performed to investigate the diversity, concentration and community structure of culturable airborne fungi in different outdoor environments of Tianjin City, using an HAS-100B air sampler. A total of 1,015 fungal strains belonging to 175 species and 82 genera of Ascomycota 92.5%, Basidiomycota 7%, and Mucoromycota 0.3% were isolated and identified using morphological and molecular analysis. The most abundant fungal genera were Alternaria 35%, Cladosporium 18%, Penicillium 5.6%, Talaromyces 3.9%, Didymella 3%, and Aspergillus 2.8%, while the most frequently occurring species were A. alternata (24.7%), C. cladosporioides (11%), A. tenuissima (5.3%), P. oxalicum (4.53%), and T. funiculosus (2.66%). The fungal concentration ranged from 0 to 340 CFU/m³ during the whole study. Environmental factors, including temperature, relative humidity, wind speed, and air pressure exerted a varying effect on the presence and concentration of different fungal taxa. The four analyzed seasons showed significantly different airborne fungal communities, which were more strongly influenced by air temperature and relative humidity in spring and summer, whereas wind speed and air pressure had a stronger effect in autumn and winter. Fungal communities from green and busy sites did not show significant differences over the four analyzed seasons, which may be due to the effect of the surrounding environments characterized by high human activities on the air of the relatively small parks present in Tianjin. The present study provided valuable information on the seasonal dynamics and the environmental factors shaping the diversity and concentration of the analyzed outdoor airborne fungal communities, which can be of help for air quality monitoring, microbial contamination control, and health risk assessment in urban environments.

Hospital indoor air quality and its relationships with building design, building operation, and occupant-related factors: A mini-review

Indoor air quality (IAQ) has recently gained substantial traction as the airborne transmission of infectious respiratory disease becomes an increasing public health concern. Hospital indoor environments are complex ecosystems and strategies to improve hospital IAQ require greater appreciation of its potentially modifiable determinants, evidence of which are currently limited. This mini-review updates and integrates findings of previous literature to outline the current scientific evidence on the relationship between hospital IAQ and building design, building operation, and occupant-related factors. Emerging evidence has linked aspects of building design (dimensional, ventilation, and building envelope designs, construction and finishing materials, furnishing), building operation (ventilation operation and maintenance, hygiene maintenance, access control for hospital users), and occupants' characteristics (occupant activities, medical activities, adaptive behavior) to hospital IAQ. Despite the growing pool of IAQ literature, some important areas within hospitals (outpatient departments) and several key IAQ elements (dimensional aspects, room configurations, building materials, ventilation practices, adaptive behavior) remain understudied. Ventilation for hospitals continues to be challenging, as elevated levels of carbon monoxide, bioaerosols, and chemical compounds persist in indoor air despite having mechanical ventilation systems in place. To curb this public health issue, policy makers should champion implementing hospital IAQ surveillance system for all areas of the hospital building, applying interdisciplinary knowledge during the hospital design, construction and operation phase, and training of hospital staff with regards to operation, maintenance, and building control manipulation. Multipronged strategies targeting these important determinants are believed to be a viable strategy for the future control and improvement of hospital IAQ.

Comparative risk assessment of COVID‐19 associated mucormycosis and aspergillosis: A systematic review

COVID‐19 is not only limited to a defined array but also has expanded with several secondary infections. Two uncommon opportunistic fungal infections, COVID‐19 associated mucormycosis (CAM) and aspergillosis (CAA), have recently been highly acquainted by many worldwide cases. Two immune response deteriorating factors are considered to be responsible for immunosuppression: comorbidities and medication. Due to unlike infection sites and patterns, CAM and CAA‐associated factors deflect a few degrees of proximity, and the present study is for its assessment. The study evaluated 351 CAM cases and 191 CAA cases retrieved from 65 and 53 articles based on inclusion criteria, respectively. Most of the CAM reported from India and CAA were from four South‐European and West‐European neighbor countries. The mean ages of CAM and CAA were 52.72 ± 13.74 and 64.81 ± 11.14, correspondingly. Mortality of CAA (56.28%) was two times greater than CAM (26.02%). Nevertheless, the count of diabetes cases was very high in CAM compared to CAA. The main comorbidities of CAM were diabetes (nearly 80%) and hypertension (more than 38%). All noticeable complications were higher in CAA except diabetes, and these were diabetes (34.55%), hypertension (45.03%), and obesity (18.32%). Moreover, pre‐existing respiratory complications like asthma and chronic obstructive pulmonary disease are visible in CAA. The uses of steroids in CAM and CAA were nearly 70% and 66%, respectively. Almost one‐fourth of CAA cases were reported using immunosuppressant monoclonal antibodies, whereas only 7.69% were for CAM. The overall finding highlights diabetes, hypertension, and steroids as the risk factors for CAM, whereas obesity, chronic pulmonary disease, and immunosuppressants for CAA.

Room HVAC Influences on the Removal of Airborne Particulate Matter: Implications for School Reopening during the COVID-19 Pandemic

(1) Background: Many schools and higher education settings have confronted the issue of reopening their facilities after the COVID-19 pandemic. In response, several airflow strategies spanning from adding portable air purifiers to major mechanical overhauls have been suggested to equip classrooms with what is necessary to provide a safe and reliable environment. Yet, there are many unknowns about specific contributions of the building system and its design and performance on indoor air quality (IAQ) improvements. (2) Methods: this study examined the combined effect of ventilation type, airflow rates, and filtration on IAQ in five different classrooms. Experiments were conducted by releasing inert surrogate particles into the classrooms and measuring the concentrations in various locations of the room. (3) Results: we showed that while the distribution of particles in the space is a complex function of space geometry and air distribution configurations, the average decay rate of contaminants is proportional to the number of air changes per hour in the room. (4) Conclusions: rooms with a central HVAC system responded quicker to an internal source of contamination than rooms with only fan coil units. Furthermore, increasing the ventilation rate without improved filtration is an inefficient use of energy.

Analysis of culturable airborne fungi in outdoor environments in Tianjin, China

Background

Fungal spores dispersed in the atmosphere may become cause of different pathological conditions and allergies for human beings. A number of studies have been performed to analyze the diversity of airborne fungi in different environments worldwide, and in particular in many urban areas in China. We investigated, for the first time, the diversity, concentration and distribution of airborne fungi in Tianjin city. We sampled 8 outdoor environments, using open plate method, during a whole winter season. Isolated fungi were identified by morphological and molecular analysis. Environmental factors which could influence the airborne fungi concentration (temperature, humidity, wind speed, and air pressure) were monitored and analyzed. The effect of different urban site functions (busy areas with high traffic flow and commercial activities vs. green areas) on airborne fungal diversity was also analyzed.

Results

A total of 560 fungal strains, belonging to 110 species and 49 genera of Ascomycota (80 %), Basidiomycota (18 %), and Mucoromycota (2 %) were isolated in this study. The dominant fungal genus was Alternaria (22 %), followed by Cladosporium (18.4 %), Naganishia (14.1 %), Fusarium (5.9 %), Phoma (4.11 %), and Didymella (4.8 %). A fungal concentration ranging from 0 to 3224.13 CFU m^− 3 was recorded during the whole study. Permutational multivariate analysis showed that the month was the most influential factor for airborne fungal community structure, probably because it can be regarded as a proxy of environmental variables, followed by wind speed. The two analyzed environments (busy vs. green) had no detectable effect on the air fungal community, which could be related to the relatively small size of parks in Tianjin and/or to the study season.

Conclusions

Our study shed light on the highly diverse community of airborne fungi characterizing the outdoor environments of Tianjin, and clarified the role that different environmental factors played in shaping the analyzed fungal community. The dominant presence of fungi with potential hazardous effect on human health, such as Alternaria, Cladosporium and Naganishia, deserves further attention. Our results may represent a valuable source of information for air quality monitoring, microbial pollution control, and airborne diseases prevention.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12866-021-02205-2.

Aspergillus spp. prevalence in Primary Health Care Centres: Assessment by a novel multi-approach sampling protocol

Exposure to Aspergillus conidia may cause adverse effects on human health; however, no specific recommendations for routine assessments of Aspergillus in the clinical environment have been suggested so far. This study intended to determine the prevalence of Aspergillus in the clinical environment, focusing on ten Primary Health Care Centres (PHCC) through a novel multi-approach sampling protocol. Air and passive sampling, culture-based methods and a probe-based real-time assay for the detection of four clinically relevant Aspergillus sections were performed. Aspergillus spp. was observed in all PHCC, with highest prevalence on floor surface swabs (n=81) (18% on MEA; 6.94% on DG18). Regarding air samples (n=81), highest Aspergillus counts were found in the waiting room (94% MEA; 18% DG18), where Nigri was the most prevalent Aspergillus section. The use of a multi-approach sampling protocol to assess Aspergillus burden in the analysed PHCC has greatly contributed to risk characterization, highlighting the need to implement corrective measures in order to avoid fungal presence in those settings.

Indoor Air Quality in Inpatient Environments: A Systematic Review on Factors that Influence Chemical Pollution in Inpatient Wards

Introduction

Indoor air quality is one the main issues in which governments are focusing. In healing spaces, several research studies are reporting a growing number of data analysis and research works in order to guarantee and prevent health of users and workers. Currently the main investigations are about biological and physical risks; otherwise chemical ones are less investigated. Several countries are carrying out indoor air quality monitoring in those professional workplaces in which chemicals are used but also in some typically indoor (generic) spaces for the building hygiene assessment. The indoor air is affected by several factors that currently are analyzed punctually, without a whole scenario of all the variable performances. The authors have done a systematic review on the current state of the art and knowledge related to chemical pollution in healing spaces and the emerging strategies, supported by scientific literature, for healthy inpatient rooms and their indoor air.

Methodology

The systematic review has been done through the analysis of papers from SCOPUS, DOAJ, and PubMed databases. The survey sample considered 483 scientific articles, between 1989 and 2017, and starting the systematic reading and analysis of the abstracts, only 187 scientific papers were selected, and only 96 were accessible.

Discussion

Since scientific literature reports very different outputs and results, the resulting work from the survey is divided into specific fields of interest related to construction and finishing materials, installations, components, ventilation systems, processes, etc. Starting from the systematic reading, the paper classifies the factors of indoor air in four macroareas: outdoor air and microclimatic factors (temperature, relative humidity, air velocity, air change, etc.); management activities (management and maintenance activities, ventilation systems, HVAC, cleaning and disinfectant activities, etc.); design factors (room dimensions, furniture, finishing materials, etc.); and human presence and medical activities (users' presence, their health status, and medical activities carried out in inpatient rooms).

Conclusion

The systematic review gives rise to a broad scenario on the existing knowledge regarding the indoor air pollution, design, and management strategies for healthy spaces and several emerging topics. Although the aim of the investigation is strictly related to chemical pollution, several considerations from the biological point of view have been listed. The systematic review, supported by the existing scientific literature, becomes a starting point for considering the importance of the topic and to stimulate the knowledge around this field of interest for improving studies, analysis, and simulations.

Aspergillus prevalence in air conditioning filters from vehicles: Taxis for patient transportation, forklifts, and personal vehicles

The frequency and importance of Aspergillus infections is increasing worldwide. This study aimed to assess the occupational exposure of forklifts and taxi drivers to Aspergillus spp. Nineteen filters from air conditioning system of taxis, 17 from forklifts and 37 from personal vehicles were assessed. Filters extract were streaked onto MEA, DG18 and in azole-supplemented media. Real-time quantitative PCR amplification of selected Aspergillus species-complex was also performed. Forklifts filter samples presented higher median values. Aspergillus section Nigri was the most observed in forklifts filters in MEA (28.2%) and in azole-supplemented media. DNA from Aspergillus sections Fumigati and Versicolores was successfully amplified by qPCR. This study enlightens the added value of using filters from the air conditioning system to assess Aspergillus spp. occupational exposure. Aspergillus azole resistance screening should be included in future occupational exposure assessments.

A scoping review on bio-aerosols in healthcare and the dental environment

Background

Bio-aerosols originate from different sources and their potentially pathogenic nature may form a hazard to healthcare workers and patients. So far no extensive review on existing evidence regarding bio-aerosols is available.

Objectives

This study aimed to review evidence on bio-aerosols in healthcare and the dental setting. The objectives were 1) What are the sources that generate bio-aerosols?; 2) What is the microbial load and composition of bio-aerosols and how were they measured?; and 3) What is the hazard posed by pathogenic micro-organisms transported via the aerosol route of transmission?

Methods

Systematic scoping review design. Searched in PubMed and EMBASE from inception to 09-03-2016. References were screened and selected based on abstract and full text according to eligibility criteria. Full text articles were assessed for inclusion and summarized. The results are presented in three separate objectives and summarized for an overview of evidence.

Results

The search yielded 5,823 studies, of which 62 were included. Dental hand pieces were found to generate aerosols in the dental settings. Another 30 sources from human activities, interventions and daily cleaning performances in the hospital also generate aerosols. Fifty-five bacterial species, 45 fungi genera and ten viruses were identified in a hospital setting and 16 bacterial and 23 fungal species in the dental environment. Patients with certain risk factors had a higher chance to acquire Legionella in hospitals. Such infections can lead to irreversible septic shock and death. Only a few studies found that bio-aerosol generating procedures resulted in transmission of infectious diseases or allergic reactions.

Conclusion

Bio-aerosols are generated via multiple sources such as different interventions, instruments and human activity. Bio-aerosols compositions reported are heterogeneous in their microbiological composition dependent on the setting and methodology. Legionella species were found to be a bio-aerosol dependent hazard to elderly and patients with respiratory complaints. But all aerosols can be can be hazardous to both patients and healthcare workers.

Assessment of multi-contaminant exposure in a cancer treatment center: a 2-year monitoring of molds, mycotoxins, endotoxins, and glucans in bioaerosols

Indoor air quality in health care facilities is a major public health concern, particularly for immunocompromised patients who may be exposed to microbiological contaminants such as molds, mycotoxins, endotoxins, and (1,3)-ß-D-glucans. Over 2 years, bioaerosols were collected on a monthly basis in a cancer treatment center (Centre F. Baclesse, Normandy, France), characterized from areas where there was no any particular air treatment. Results showed the complexity of mycoflora in bioaerosols with more than 100 fungal species identified. A list of major strains in hospital environments could be put forward due to the frequency, the concentration level, and/or the capacity to produce mycotoxins in vitro: Aspergillus fumigatus, Aspergillus melleus, Aspergillus niger, Aspergillus versicolor, Cladosporium herbarum, Purpureocillium lilacinum, and Penicillium brevicompactum. The mean levels of viable airborne fungal particles were less than 30.530 CFU per m³ of air and were correlated to the total number of 0.30 to 20 μm particles. Seasonal variations were observed with fungal particle peaks during the summer and autumn. Statistical analysis showed that airborne fungal particle levels depended on the relative humidity level which could be a useful indicator of fungal contamination. Finally, the exposure to airborne mycotoxins was very low (only 3 positive samples), and no mutagenic activity was found in bioaerosols. Nevertheless, some fungal strains such as Aspergillus versicolor or Penicillium brevicompactum showed toxigenic potential in vitro.

In-hospital transfer is a risk factor for invasive filamentous fungal infection among hospitalized patients with hematological malignancies: a matched case-control study

OBJECTIVE

Immunocompromised patients now benefit from a longer life expectancy due to advanced medical techniques, but they are also weakened by aggressive treatment approaches and are at high risk for invasive fungal disease. We determined risk factors associated with an outbreak of invasive filamentous fungal infection (IFFI) among hospitalized hemato-oncological patients.

METHODS

A retrospective, matched, case-control study was conducted between January 1, 2009, and April 31, 2011, including 29 cases (6 proven, 8 probable, and 15 possible) of IFFI and 102 matched control patients hospitalized during the same time period. Control patients were identified from the hospital electronic database. Conditional logistic regression was performed to identify independent risk factors for IFFI.

RESULTS

Overall mortality associated with IFFI was 20.7% (8.0%-39.7%). Myelodysplastic syndrome was associated with a higher risk for IFFI compared to chronic hematological malignancies. After adjustment for major risk factors and confounders, >5 patient transfers outside the protected environment of the hematology ward increased the IFFI risk by 6.1-fold. The risk increased by 6.7-fold when transfers were performed during neutropenia.

CONCLUSION

This IFFI outbreak was characterized by a strong association with exposure to the unprotected environment outside the hematology ward during patient transfer. The independent associations of a high number of transfers with the presence of neutropenia suggest that affected patients were probably not sufficiently protected during transport in the corridors. Our study highlights that a heightened awareness of the need for preventive measures during the entire care process of at-risk patients should be promoted among healthcare workers.

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.

Surveillance of patients identified with fungal mold at a public academic medical center

BACKGROUND

This study describes the epidemiology of patients with fungal mold infection or colonization at a large academic medical center during a period of ongoing construction of a new hospital building.

METHODS

This is an observational retrospective cohort study performed at a public academic hospital. We performed focused medical record review of all patients with fungal mold isolated on microbiologic culture over a 3-year period from May 2009 through April 2012. We established case definitions by modifying criteria used in previously published studies. We established 4 categories for invasiveness: proven invasive fungal disease (IFD), probable IFD, clinical infection not meeting IFD criteria, or colonization/contamination. We also established 3 categories for association with our health care facilities: health care-associated hospital onset (HO), health care-associated community onset (HACO), or community associated (CA).

RESULTS

Of the 188 cases included in the study, 15 (7.9%) and 23 (12.2%) met criteria for proven and probable IFD, respectively. Of the cases, 114 (60.6%) represented contamination or colonization, and 36 (19.1%) had clinical infection not meeting IFD criteria. Epidemiologically, 46 (24.5%) cases were HO, 42 (22.3%) cases were HACO, and 100 (53.2%) cases were CA.

CONCLUSION

The surveillance methods we established were helpful for characterizing and monitoring fungal mold infections at the study institution.

Occupational exposure to Aspergillus and aflatoxins among food-grain workers in India

BACKGROUND

Aflatoxins are a metabolite of Aspergillus molds and are widespread in the natural environment. Workers who handle food grains are at increased risk of exposure to aflatoxins and subsequently certain respiratory conditions. In India, more than half of the employed population is engaged in some type of agricultural work, yet little known about the respiratory problems as a result of exposure to aflatoxins among workers who handle food grains in India.

OBJECTIVES

The aim of this study was to determine the risk of occupational exposure to aflatoxins in food-grain workers compared to workers who are not occupationally exposed to food grains.

METHODS

Bronchoalveolar lavage (BAL) and serum samples from 46 food-grain workers and 44 non-food-grain workers were analyzed for the presence of aflatoxins. Microscopy and culture of BAL samples were performed to detect Aspergillus species.

RESULTS

Aflatoxins were detected in 32·6% of the food-grain workers and 9·1% of non food grain workers (P<0·01). A significant difference was also found in BAL culture for Aspergillus (P<0·01) between the two groups. About 47·8% of the food-grain workers and 11·4% of non-food-grain workers had chronic respiratory symptoms.

CONCLUSION

Occupational exposure to aflatoxins in food-grain workers was found to be associated with the increased presence of respiratory symptoms.

Pulmonary aspergillosis and aflatoxins in chronic lung diseases

Fungal infections of lung have become increasingly common during the last few decades. Aspergillosis and the role of aflatoxins in various chronic lung diseases have not been extensively studied. Bronchoalveolar lavage (BAL) samples and sera from 40 patients of chronic lung diseases were analyzed for galactomannan antigen (GM) and aflatoxin by enzyme-linked immunosorbent assay. Direct microscopy and culture of BAL samples were also done to detect the Aspergillus species. Results revealed that 15 (37.5 %) of the 40 patients had growth of Aspergillus on BAL culture. Out of these culture-positive cases, 13 (86.7 %) patients were positive for galactomannan antigen also. About 62.5 % cases did not show growth of Aspergillus in BAL culture. However, galactomannan antigen could be detected in 20 % of these patients. Overall, 20 % patients were diagnosed as proven invasive fungal disease (IFD), 32.5 % were of probable IFD, 17.5 % of possible IFD. Aspergillus growth was observed in 100 % of proven and 53.8 % of probable IFD cases. Galactomannan antigen was found in 100 % cases of proven and 76.9 % of probable IFD. Ten (25 %) patients were found to be positive for aflatoxins. It was detected in 6 (40 %) of culture-positive cases. About 62.5 % of the cases with proven IFD and 46.1 % of probable IFD had aflatoxin in their samples. Aflatoxin positivity was found to be more in patients with proven IFD than in probable IFD, and higher level of aflatoxins was detected in cases with proven IFD. Significant difference was observed in aflatoxin positivity among food grain workers when compared to other occupations.

Antimicrobial prophylaxis and outpatient management of fever and neutropenia in adults treated for malignancy: American Society of Clinical Oncology clinical practice guideline

PURPOSE

To provide guidelines on antimicrobial prophylaxis for adult neutropenic oncology outpatients and on selection and treatment as outpatients of those with fever and neutropenia.

METHODS

A literature search identified relevant studies published in English. Primary outcomes included: development of fever and/or infections in afebrile neutropenic outpatients and recovery without complications and overall mortality in febrile neutropenic outpatients. Secondary outcomes included: in afebrile neutropenic outpatients, infection-related mortality; in outpatients with fever and neutropenia, defervescence without regimen change, time to defervescence, infectious complications, and recurrent fever; and in both groups, hospital admissions, duration, and adverse effects of antimicrobials. An Expert Panel developed guidelines based on extracted data and informal consensus.

RESULTS

Forty-seven articles from 43 studies met selection criteria.

RECOMMENDATIONS

Antibacterial and antifungal prophylaxis are only recommended for patients expected to have < 100 neutrophils/μL for > 7 days, unless other factors increase risks for complications or mortality to similar levels. Inpatient treatment is standard to manage febrile neutropenic episodes, although carefully selected patients may be managed as outpatients after systematic assessment beginning with a validated risk index (eg, Multinational Association for Supportive Care in Cancer [MASCC] score or Talcott's rules). Patients with MASCC scores ≥ 21 or in Talcott group 4, and without other risk factors, can be managed safely as outpatients. Febrile neutropenic patients should receive initial doses of empirical antibacterial therapy within an hour of triage and should either be monitored for at least 4 hours to determine suitability for outpatient management or be admitted to the hospital. An oral fluoroquinolone plus amoxicillin/clavulanate (or plus clindamycin if penicillin allergic) is recommended as empiric therapy, unless fluoroquinolone prophylaxis was used before fever developed.

Distribution characteristics of airborne bacteria and fungi in the general hospitals of Korea

The objective of this study is to provide fundamental data related to size-based characteristics of bioaerosol distributed in the general hospital. Measurement sites are main lobby, ICU, surgical ward and biomedical laboratory and total five times were sampled with six-stage cascade impactor. Mean concentrations of airborne bacteria and fungi were the highest in main lobby as followed by an order of surgical ward, ICU and biomedical laboratory. The predominant genera of airborne bacteria identified in the general hospital were Staphylococcus spp. (50%), Micrococcus spp. (15-20%), Corynebacterium spp. (5-20%), and Bacillus spp. (5-15%). On the other hand, the predominant genera of airborne fungi identified in the general hospital were Cladosporium spp. (30%), Penicillium spp. (20-25%), Aspergillus spp. (15-20%), and Alternaria spp. (10-20%). The detection rate was generally highest on stage 5 (1.1-2.1 microm) for airborne bacteria and on stage 1 (>7.0 microm) for airborne fungi.

Sporotrichoid aspergillosis in an immunocompromised child: a case report and review of the literature

Primary cutaneous aspergillosis is an uncommon, opportunistic infection. Atypical presentations have recently emerged with the expanding range of primary and acquired diseases that cause immunosuppression. Primary cutaneous aspergillosis may invade the deep lymphatic structures and present in a sporotrichoid pattern. In pediatric patients with an otherwise normal previous medical history, primary cutaneous aspergillosis should raise the suspicion of an immunodeficiency and prompt referral to immunology and infectious disease specialists should be made. Early diagnosis and management of primary cutaneous aspergillosis prevents invasive aspergillosis, minimizing morbidity and mortality in the immunocompromised patients.

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

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

Construction: a model program for infection control compliance

ISSUE

In the 21st century, one of the most challenging tasks for the infection control practitioner (ICP) is establishing collegiality and trust with contractors, architects, maintenance and engineering personnel. We describe how an urban teaching hospital's infection control program cooperated with contractors during a large demolition, construction, and renovation project in order to protect its large population of immunosuppressed patients.

PROJECT

Most contractors are not accustomed to taking special precautions during demolition. Because of a previous Aspergillus outbreak in our heart transplant population, we already had an established infection control (IC) training program for contractors. We expanded and codified it in response to a major hospital renovation. The IC, in-house Design and Construction, and outside contractors meet before the initiation of all major renovation projects to anticipate IC concerns and proactively plan for infection control interventions. Now, all contractors and maintenance staff are required to receive IC training at the time of their employment. A hospital identification badge with attached sticker that indicates the IC training date is required. Infection Control Risk Assessments (ICRA) are initiated by project managers and completed jointly with IC. The ICPs make rounds on all projects at least weekly and large projects are visited daily. We established a team comprised of ICP, project manager, construction manager, and area nurse manager to monitor and make recommendations for improvement continually during the project. Staff are educated about construction so they can help monitor airflow and cleanliness.

RESULTS

Our contractors are more compliant with our IC specifications since they now understand why we insist on them. Through the years of major construction, the workers have jumped on the bandwagon. It is not unusual for construction or maintenance staff to contact IC for advice. There were four years of extensive construction without any hospital acquired Aspergillus infections. In the 5th year, after a neighboring institution started demolition and new construction, we identified two possible nosocomial infections and took immediate steps to make more corrections. There have been no further infections.

LESSONS LEARNED

The IC compliance is based on trust, education, and on-going monitoring. Proactive education and collaboration lead to long-term relationships, trust and patient safety.

OBJECTIVE

This article describes how a large teaching hospital's infection prevention program achieved compliance from contractors during a large renovation.

Epidemiologische Grundlagen

Eine Vielzahl an Faktoren tragen zu erhöhten nosokomialen Infektionsraten bei. Die Lebenserwartung und damit der Anteil alter Patienten mit z. T. chronischen Krankheiten steigen stetig an. Medizinische Fortschritte in Diagnostik und Therapie führen zu einer höheren Anzahl der dafür erforderlichen Eingriffe. Es werden immer häufiger immunsupprimierte Patienten (Infektiologie, Rheumatologie, Hämatologie/Onkologie, Transplantation von Organen usw.) behandelt. Das zunehmende Problem der Antibiotikaresistenz von Erregern und die Konsequenzen nosokomialer Infektionen erfordern eine verlässliche Epidemiologie auf diesem Gebiet. Konsequenzen betreffen einerseits Patienten, bei denen es zu einer erhöhten Morbidität und Letalität durch nosokomiale Infektionen kommt, aber andererseits auch das Gesundheitswesen, dem zusätzliche — vermeidbare? — finanzielle Belastungen entstehen.

Evidenzbasierte Empfehlungen, bei denen der jeweilige Einzelfall und die örtlichen Besonderheiten ebenfalls Berücksichtigung finden, sind Voraussetzung für eine sinnvolle und kosteneffektive Vorgehensweise zur Senkung der nosokomialen Infektionsrate. In vielen Studien sind Häufigkeiten und Folgen verschiedener nosokomialer Infektionsarten sowie Maßnahmen zu ihrer Prävention untersucht worden. Um die Qualität solcher Studien und die darauf basierenden Empfehlungen von Experten, die ja oftmals ebenfalls mit Kosten verbunden sind, kritisch beurteilen zu können, ist epidemiologisches Wissen unverzichtbar. Dies beinhaltet selbstverständlich auch die Kenntnis der jeweiligen Erreger solcher Infektionen sowie das Wissen um erregerspezifische Übertragungswege. Die Epidemiologie nosokomialer Infektionen ist daher die Grundlage ihrer eigenen Verbesserung.

»Es gibt nicht Kranke und Gesunde, sondern es gibt nur Untersuchte und nicht Untersuchte« (Johannes Rau, ehemaliger Bundespräsident).

Microbial Contamination in Airplane Cabins:Health Effects and Remediation

Microorganisms that affect human health are found in all indoor environments, including cabins of commercial aircraft. Those that arise from human sources can be transmitted by direct contact, droplets, or the airborne route. Infections from human sources include Influenza, Rhinovirus, SARS and tuberculosis. Transmission by the airborne route can be reduced by sterilizing the air with ultraviolet germicidal irradiation, or by diluting the contaminated air with outdoor air through ventilation. Microbes arising from environmental sources include bacteria, fungi and other organisms such as protozoa. These usually have very simple requirements for growth – water and a simple substrate such as dust. They cause health effects through direct infection rarely (one example is Legionnella), but more commonly cause immune reactions resulting in hypersensitivity or allergy mediated diseases. Environmental sources of microbial contamination are best prevented, but can be remediated through cleaning, germicidal chemicals, or ultraviolet germicidal irradiation. Airborne microbial substances including toxins, antigens and viable organisms can be removed by outdoor air ventilation or filtration. In aircraft cabins transmission of pathogens from human sources is difficult to control, but airborne transmission can be reduced through increased outdoor air ventilation or filtration. Environmental microbial contamination can, and does occur in aircraft cabins. These microbial sources are best prevented but, if detected, can be removed through cleaning or disinfection. Ultraviolet germicidal irradiation is an under-utilized technology that may be useful for sterilizing air as well as potential environmental sources.

Primary cutaneous aspergillosis (PCA)--a case report

Primary cutaneous aspergillosis is a rare diagnosis. Predisposing factors are immunodeficiency and macerated skin. The mortality of infections with Aspergillus species is high, especially in neonatal intensive care units (NICUs). We present a premature (24 wk of gestation) infant with primary cutaneous aspergillosis appearing on the sixth day of life. Predisposing factors in this patient were prematurity, extremely vulnerable skin, treatment with antibiotics and renovation in the radiology department nearby. The patient was treated with amphotericin B intravenously for a total of 40 d. He did not have, nor develop, disseminated aspergillosis, and suffered no side effects from the treatment. The only remaining trace of his infection was scarring in the affected area.

CONCLUSION

After having treated this patient successfully and having gone through the available literature, we conclude that treating primary cutaneous aspergillosis with intravenous amphotericin B prevents disseminated aspergillosis and is the treatment of choice.

Aspergillus surveillance project at a large tertiary-care hospital

A one-year surveillance project was conducted at a large tertiary hospital, which had extensive indoor renovation and extensive demolition/building at several nearby sites. This study collected viable fungi samples in the hospital every six days and analysed 74 duct dust samples for Aspergillus fumigatus mycelial asp f1 protein. Mean total fungi were 257.8 cfu/m3 outdoors, 53.2 cfu/m3 in all indoor samples and 83.5 cfu/m3 in the bone marrow transplant patient rooms. Mean total aspergillus was 6.8 cfu/m3 outdoors, 12.1 cfu/m3 in all indoor samples and 7.3 cfu/m3 in the bone marrow transplant patient rooms. The five most prevalent Aspergillus species collected inside the hospital (mean cfu/m3) were Aspergillus niger 7.57 cfu/m3, Aspergillus candidus 1.72 cfu/m3, Aspergillus flavus 0.97 cfu/m3, A. fumigatus 0.88 cfu/m3 and Aspergillus glaucus 0.45 cfu/m3. In rooms undergoing duct cleaning, mean A. fumigatus concentrations were 11.0 cfu/m3. Forty-eight of 74 (65%) duct dust samples had measurable levels of asp f1 protein, with a mean level of 0.41 ppm and maximum level of 1.94 ppm. Three major incidents involved increased hospital aspergillus concentrations. A. niger levels reached 680 cfu/m3 in an organ transplant room after a water leak from a ceiling pipe. Total aspergillus concentrations rose to 77 cfu/m3 in a bone marrow transplant patient room after improper sealing and water infiltration of the unit's dedicated high-efficiency particulate air filter system. Total aspergillus levels of 160 cfu/m3 were recorded in a renovation area during wood cutting. The higher concentrations of aspergillus seen inside the hospital compared with outdoors and the various moisture/HEPA filter/renovation incidents suggest that numerous small to moderate sources of aspergillus exist in the hospital.

Aspergillose pulmonaire invasive chez les enfants immunodeṕrimés méthodes diagnostiques et classification

Invasive aspergillosis is an opportunistic infection, with frequent lung involvement. High-risk children are allogenic bone marrow recipients, and those with hematological malignancies, aplastic anemia or chronic granulomatous disease. Profound and prolonged neutropenia, and corticosteroid therapy are the most important predisposing factors. Building and demolition works represent the major environmental risk factor. The diagnosis of invasive aspergillosis remains difficult to establish. Clinical manifestations are non-specific. Early thoracic computed tomographic scan shows halo sign in most cases. Subsequently appears the air crescent sign. Galactomannan research by sandwich ELISA can be useful in serum and in bronchoalveolar lavage fluid. Aspergillus DNA detection by PCR is still not standardized. Culture of the organism allows species identification. Aspergillus hyphae can be found at cytological examination, but a biopsy specimen is usually required to affirm tissue damage. A new classification of invasive fungal infections in immunocompromised patients was recently proposed by experts from the European Organization for Research and Treatment of Cancer and from the Mycoses Study Group of the National Institute of Allergy and Infectious Diseases. On the basis of host linked criteria, microbiological, clinical and radiological features, invasive aspergillosis is classified as proven, probable or possible. These definitions should not be used to guide clinical practice in therapy, but they will improve the quality of epidemiological data, and help the comparison of clinical trial results.

Organizational and environmental factors that affect worker health and safety and patient outcomes

This article reviews organizational factors that influence the satisfaction, health, safety, and well-being of health care workers and ultimately, the satisfaction, safety, and quality of care for patients. The impact of the work environment on working conditions and the effects on health care workers and patients are also addressed. Studies focusing on worker health and safety concerns affected by the organization and the physical work environment provide evidence of direct positive and/or adverse effects on performance and suggest indirect effects on the quality of patient care. The strongest links between worker and patient outcomes are demonstrated in literature on nosocomial transmission of infections. Transmission of infections from worker to patient and from patient to patient via health care worker has been well documented in clinical studies. Literature on outbreaks of infectious diseases in health care settings has linked the physical environment with adverse patient and worker outcomes. An increasing number of studies are looking at the relationship between improvement in organizational factors and measurable and positive change in patient outcomes. Characteristics of selected magnet hospitals are reviewed as one model for improving patient and worker outcomes.

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

Nosocomial aspergillosis, a life-threatening infection in immunocompromised patients, is thought to be caused primarily by Aspergillus organisms in the air. A 3-year prospective study of the air, environmental surfaces, and water distribution system of a hospital in which there were known cases of aspergillosis was conducted to determine other possible sources of infection. Aspergillus species were found in the hospital water system. Significantly higher concentrations of airborne aspergillus propagules were found in bathrooms, where water use was highest (2.95 colony-forming units [cfu]/m(3)) than in patient rooms (0.78 cfu/m(3); P=.05) and in hallways (0.61 cfu/m(3); P=.03). A correlation was found between the rank orders of Aspergillus species recovered from hospital water and air. Water from tanks yielded higher counts of colony-forming units than did municipal water. An isolate of Aspergillus fumigatus recovered from a patient with aspergillosis was genotypically identical to an isolate recovered from the shower wall in the patient's room. In addition to the air, hospital water systems may be a source of nosocomial aspergillosis.

Risk factors for the development of invasive fungal infections in allogeneic blood and marrow transplant recipients

Blood and marrow transplantation (BMT) is increasingly used to treat malignant and nonmalignant diseases. Despite significant advances in the management of transplant recipients, however, fungal infections remain important life-threatening complications of BMT. Over the past two decades, the incidence of fungal infections in this population has continued to rise. Several factors predispose BMT recipients to invasive fungal infections. These include but are not limited to use of intensive myeloablative chemotherapy and radiation therapy combined with prolonged granulocytopenia; development of acute and chronic graft-versus-host disease; administration of immunosuppressive therapy, particularly using corticosteroids; use of central venous catheters; and prolonged impairment of cell-mediated immunity secondary to the underlying disease and post-transplant immunodeficiency. Environmental factors also play a key part in the pathogenesis of fungal infections. Therefore, infection-control measures are critical to the prevention of such infections. In addition, although Candida and Aspergillus species are still the major culprits, other opportunistic fungi have emerged in recent years.

Masking of neutropenic patients on transport from hospital rooms is associated with a decrease in nosocomial aspergillosis during construction

To prevent nosocomial pulmonary aspergillosis during hospital construction, neutropenic patients with hematologic malignancy were required to wear high-efficiency masks when leaving their rooms. The rate of nosocomial aspergillosis decreased from 0.73 per 1,000 hospital patient-days during fiscal years 1993 to 1996 to 0.24 per 1,000 hospital patient-days during fiscal years 1996 to 1999 (P < .001). High-efficiency masks reduced nosocomial aspergillosis during hospital construction.

Relationship between environmental fungal contamination and the incidence of invasive aspergillosis in haematology patients

Invasive aspergillosis (IA) is a major opportunistic infection in haematology patients. Spore inhalation is the usual route of Aspergillus infection, suggesting a determining role of environmental contamination by spores in the epidemiology of IA. We prospectively examined the relationship between environmental contamination by Aspergillus and other fungal species and the incidence of invasive nosocomial aspergillosis (INA) in a bone marrow transplantation unit and two haematology wards. During a four-year period, levels of air and surface fungal contamination were determined bi-monthly in patients' rooms (some equipped with HEPA filters and LAF systems), and various common sites in each ward (corridors, nursing stations, etc.). Results were compared to the incidence of INA. A total of 3100 air and 9800 surface samples were collected, and 79 cases of IA were diagnosed, of which 64 were probably or possibly INA. Patterns of fungal contamination were comparable in the three wards, with a gradient ranging from high levels in common sites to a virtual absence in rooms equipped with HEPA filters and LAF systems. Using a regression model, a significant relationship was found between the incidence of INA and the degree of fungal contamination of air and surfaces in conventional patient rooms (not equipped with HEPA) and common sites. This study shows that in a non-epidemic setting, there is a significant relationship between environmental fungal contamination in haematology wards and the incidence of INA. Our findings underline the importance of environmental surveillance and strict application of preventive measures.

Biodiversity and concentration of airborne fungi in a hospital environment

The biodiversity and concentration of airborne fungi were monitored over a period of 6 months in a special-care unit of a hospital. Air sampling was performed in a corridor that was also accessible to visitors and in an adjacent bone-marrow transplantation (BMT) unit using an air sampler and two isolation media. Altogether, 98 fungal species could be identified, among them Aspergillus fumigatus and A. terreus as well as 48 other species reported as potential pathogens. The average contamination values of the corridor air ranged from 124 to 485 cfu m-3. Neither the degree of fungal air contamination nor the species composition inside the special care unit differed from those found in the corridor. By means of data obtained with a light-activated sensor, a possible influence of human activities on diurnal changes of fungal propagule concentration was shown.

Invasive pulmonary aspergillosis in neutropenic patients during hospital construction: before and after chemoprophylaxis and institution of HEPA filters

Between September 1993 and December 1993, during extensive hospital construction and indoor renovation, a nosocomial outbreak of invasive pulmonary aspergillosis occurred in acute leukemia patients treated in a regular ward that has only natural ventilation. The observed infection rate was 50%. Chemoprophylaxis with intravenous continuous low-dose amphotericin B was then instituted as a preventive measure. During the next 18 months invasive pulmonary aspergillosis developed in 43% of acute leukemia patients. After that period a new hematology ward was opened with an air filtration system through high-efficiency particulate air filtration (HEPA) filters, and a bone marrow transplantation program was started on the hematology service. During the following three years, none of the acute leukemia or bone marrow transplantation patients who were hospitalized exclusively in the hematology ward developed invasive pulmonary aspergillosis, although 29% of acute leukemia patients who were housed in a regular ward, because of shortage of space in the new facility, still contracted invasive pulmonary aspergillosis. Overall, 31 patients were diagnosed with invasive pulmonary aspergillosis during almost five years: 74% of patients recovered from invasive pulmonary aspergillosis, and 42% are long-term survivors; 26% of patients died of resistant leukemia with aspergillosis, but no one died of invasive pulmonary aspergillosis alone. In conclusion, during an on-going construction period, an extremely high incidence rate of invasive pulmonary aspergillosis in acute leukemia patients undergoing intensive chemotherapy was observed. Institution of low-dose intravenous amphotericin B prophylaxis marginally reduced the incidence rate of invasive pulmonary aspergillosis. Keeping patients in a special ward with air filtration through a HEPA system eliminated invasive pulmonary aspergillosis completely. Among patients who developed invasive pulmonary aspergillosis, early diagnosis and treatment are probably the explanation for the favorable outcome.