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

Mycological Methods for Routine Air Sampling and Interpretation of Results in Operating Theaters

Many infectious diseases are transmitted via the air and are, therefore, particularly difficult to combat. These infections include various invasive mycoses caused by molds. The usual route of infection is the inhalation of conidia. In hospitals, infection can also occur through the deposition of conidia in otherwise sterile anatomical sites during surgical and other invasive procedures. Therefore, knowledge of airborne mold concentrations can lead to measures to protect patients from fungal infections. The literature on this topic contains insufficient and sometimes ambiguous information. This is evidenced by the fact that there are no international recommendations or guidelines defining the methodology of air sampling and the interpretation of the results obtained. Surgical departments, intensive care units and medical mycology laboratories are, therefore, left to their own devices, leading to significant differences in the implementation of mycological surveillance in hospitals. The aim of this mini-review is to provide an overview of the current methods of air sampling and interpretation of results used in medical mycology laboratories.

Assessment of fungal bioaerosols and particulate matter characteristics in indoor and outdoor air of veterinary clinics

Veterinary staff are frequently exposed to various occupational hazards. The present study was aimed to investigate the air characteristics of veterinary clinics in terms of fungal bioaerosols and particulate matters. Air samples were taken every six days from the operating room, examination room and outdoor air of three veterinary clinics in Shiraz, southwest Iran. The concentrations of fungal bio-aerosols ranged from 8.05 CFU/m ³ in the outdoor air of clinic B to 47.21 CFU/m ³ in the operating room of clinic A. The predominant fungal genera identified in the studied clinics were Penicillium and Aspergillus niger, respectively. The concentrations of PM_2.5 ranged from 41.88 μg/m ³ in the operating room of clinic C to 60.31 μg/m ³ in the outdoor air of the same clinic. The corresponding values for PM₁₀ ranged from 114.40 μg/m ³ in the operating room of clinic C to 256.70 μg/m ³ in the outdoor air of the same clinic. The results of this study showed a positive correlation between the concentration of fungal bioaerosols and relative humidity (p < 0.05; r = 0.622). Besides, a negative correlation was found between the concentration of fungal bioaerosols and temperature (p < 0.05; r = 0.369). To better assess the individual exposure of veterinarians and staff in veterinary clinics, tests including nasopharyngeal sampling are recommended.

Risks associated with pathogenic fungi isolated from surgical centers, intensive care units, and materials sterilization center in hospitals. Risks associated with pathogenic fungi isolated from critical hospital areas

The hospital environment requires special attention to air quality, since it needs to be healthy for the protection of patients and health professionals in order to prevent them against hospital infections. The objective of this study was to isolate, identify and evaluate the susceptibility profile of isolated fungi from two hospitals. For air sampling the impaction (Spin Air, IUL®) and passive sedimentation methods were used. For the isolation of fungi from surfaces, contact plates (RODAC®) were used. The identification of the fungi was performed by observing the macroscopic and microscopic aspects of the colonies, whereas for better visualization of fruiting structures, the microculture technique was performed on slides. To evaluate the susceptibility profile, the broth microdilution test recommended by CLSI was performed. Thirty-five isolates were identified: Aspergillus flavus (12), Aspergillus fumigatus (11), Aspergillus niger (1), Aspergillus terreus (2), Penicillium spp. (7), and Fusarium spp. (2) in the hospitals evaluated. All isolates had a minimum inhibitory concentration (MIC) more than 128 μg/ml for fluconazole; 0.5 to 4.0 μg/ml for amphotericin B (hospital 1), and all isolates from haospital 2 had MIC ≥2.0 μg/ml. In hospital 1, MIC for posaconazole ranged from 0.25 μg/ml to ≥32 μg/ml, and hospital 2 ranged from 0.5 to 1.0 μg/ml. The monitoring and evaluation of air quality and surfaces are essential measures for prevention and control of hospital infections, as these microorganisms are becoming increasingly resistant to antimicrobial agents, thus making treatment difficult, especially in immunocompromised individuals.

The Health Literacy Status and Its Role in Interventions in Iran: A Systematic and Meta-Analysis

There are increasing calls for public health policies to realize the visions of a health literate society and health literacy on a global scale. However, there are still more gaps in what researchers recognize and what steps they should take to improve health literacy (HL) skills. This review aimed to measure the HL status of the Iranian population and the effect size of the underlying association between HL and other health outcomes, and to examine the effectiveness of HL interventions on improving the functional dimension of HL, self-efficacy, and health-promoting behaviors. All full text published articles written in English and Persian language were included from inception until January 2019, but the type of study is not limited. A total of 52 potentially relevant articles with data on 36,523 participants were included in this review. In the population with health conditions, the average HL score was 62.51 (95% CI: 59.95-65.08), while in the patient population, the HL score was 64.04 (95% CI: 60.64-67.45). Health literacy was positively and significantly correlated with self-care behaviors 0.42 (95% CI; 0.35-0.49), self-efficacy 0.35 (95% CI; 0.26-0.43), knowledge 0.50 (95% CI; 0.44-0.55), communication skills 0.33 (95% CI; 0.25-0.41), and health promotion behaviors 0.39 (95% CI; 0.35-0.44). The meta-analyses showed that overall, HL interventions significantly improved HL status, self-efficacy, and health promotion behaviors. Results indicate that HL status was in the range of marginal HL level in the Iranian population. Our finding highlights the beneficial impact of HL intervention on health-promoting behaviors and self-efficacy, particularly in low literacy/socioeconomic status people.

Bacterial Contamination in Health Care Centers: Differences between Urban and Rural Settings

This study aims to assess the airborne bioburden of rural and urban Portuguese Primary Health Care Centers (PHCC) using active and passive sampling methods and identify the potential differences in airborne microbiota between both environments. The highest total aerobic mesophilic bacterial load in indoor air were found in the Vaccination Room (448 CFU.m−3) in the Rural PHCC and in the Waiting Room (420 CFU.m−3) for Urban PHCC. The total coliforms contamination level in indoor air was detected only in the Cleaning Supplies Room (4 CFU.m−3) in the Urban PHCC. The most frequent bacteria genera identified was Micrococcus (21% Rural PHCC; 31% Urban PHCC). The surface samples showed a highest total aerobic mesophilic bacterial contamination in the Treatment Room (86 × 103 CFU.m−2) from the Rural PHCC and in the Front Office (200 × 103 CFU.m−2) from the Urban PHCC. The electrostatic dust cloth (EDC) samples showed a highest bacterial load in the Urban PHCC. Total aerobic mesophilic bacterial load in settled dust and in the Heating, Ventilating and Air Conditioning (HVAC) filter samples in the Urban PHCC (8 CFU.g−1 and 6 × 103 CFU.m−2) presented higher values compared with the Rural PHCC (1 CFU.g−1 and 2.5 × 103 CFU.m−2). Urban PHCC presented higher bacterial airborne contamination compared with the Rural PHCC for the majority of sampling sites, and when compared with the indoor air quality (IAQ) Portuguese legislation it was the Rural PHCC in two sampling places who did not comply with the established criteria.

Investigation of fungal contamination in indoor air and on surfaces of traditional public baths in a historical city

It has been proven that exposure to bioaerosols is associated with several health effects, such as pulmonary diseases and allergies. The present cross-sectional study was aimed to investigate fungal contamination in indoor air and on the surfaces of four traditional baths in Shiraz, Iran, one of the most historical cities in the world. Samples were taken from indoor air, using a microbial air sampler, as well as the surfaces of the shower, hallway, and dressing rooms of studied baths for 3 months. Totally 180 samples, including 45 air and 135 surfaces samples, were collected from studied baths. The concentrations of fungi collected from the air of studied baths were ranged from 22.6 to 34.6 CFU/m³. Besides, the levels of fungi collected from the surface samples of studied baths were ranged from 21.2 to 60 CFU/m². The highest and lowest fungi species detected both in air and surfaces samples of the studied baths were Penicillium spp. and Mucor spp. respectively. Although the levels of fungi in the studied baths were lower than the levels recommended by the World Health Organization, some environmental health measures such as washing and disinfecting surfaces and tools after each working shift and periodic inspections are recommended ensuring the safety of costumers who are visiting such places.

Microbiological analysis of bacterial and fungal bioaerosols from burn hospital of Yazd (Iran) in 2019

INTRODUCTION

Bioaerosols play an important role in incidence of infections in indoor and outdoor air of hospitals. Microorganisms play a critical role in the health of human beings and they are found everywhere in the environment, including different wards of a hospital. So, quantitative and qualitative analysis of microorganisms is highly important in hospital air. The aim of this study was to evaluate the diversity and density of bacteria and fungi in the air of Shohadaye Mehrab Hospital in Yazd City, Iran.

MATERIALS AND METHODS

Sampling was performed using a single-stage pump (Quick Take30) at a flow rate of 28.3 l per minute for five minutes. As a result, 288 indoor and outdoor hospital air samples were collected. Numbers and types of bacterial and fungal colonies were identified using colony morphology, gram staining, and standard microbial tests. Chi-square test, PCA and linear mixed model were run by SPSS version 24.0 for data analysis.

RESULTS

The highest bacterial contaminations were found in the burns ward (294 CFU/m³), operating theater (147 CFU/m³), and emergency department (124 CFU/m³), respectively. Fungal contamination was higher in the derm ward (110 CFU/m³) than other sampling sites. The dominant genus of gram-positive bacteria was Staphylococcus epidermidis (n = 60, 62.5%) and the dominant genus of gram-negative bacteria was Citrobacter freundi (n = 11, 11.5%). The most fungal gens isolated from the hospital air samples were Penicillium (n = 73, 76%), Alternaria (n = 51, 53.1%), Aspergillus niger (n = 40, 41.7%), and Aspergillus flavus (n = 34, 35.4%), respectively.

CONCLUSION

Considering that the burn wounds represent a susceptible site for opportunistic microorganisms, even low concentration of fungi/bacteria in air can be considered as a risk factor that facilitates transmission of the infectious agents in the hospital. Therefore, control measures should be taken to reduce the infection hazard in health staff and patients. These measures include ensuring effective ventilation, cleaning and decontaminating surfaces and equipment, restricting the personnel and patient companions' movement across the wards.

Indoor hospital air and the impact of ventilation on bioaerosols: a systematic review

Healthcare-acquired infections (HAIs) continue to persist in hospitals, despite the use of increasingly strict infection-control precautions. Opportunistic airborne transmission of potentially pathogenic bioaerosols may be one possible reason for this persistence. Therefore, this study aimed to systematically review the concentrations and compositions of indoor bioaerosols in different areas within hospitals and the effects of different ventilation systems. Electronic databases (Medline and Web of Science) were searched to identify articles of interest. The search was restricted to articles published from 2000 to 2017 in English. Aggregate data was used to examine the differences in mean colony forming units per cubic metre (cfu/m³) between different hospital areas and ventilation types. A total of 36 journal articles met the eligibility criteria. The mean total bioaerosol concentrations in the different areas of the hospitals were highest in the inpatient facilities (77 cfu/m³, 95% confidence interval (CI): 55-108) compared with the restricted (13cfu/m³, 95% CI: 10-15) and public areas (14 cfu/m³, 95% CI: 10-19). Hospital areas with natural ventilation had the highest total bioaerosol concentrations (201 cfu/m³, 95% CI: 135-300) compared with areas using conventional mechanical ventilation systems (20 cfu/m³, 95% CI: 16-24). Hospital areas using sophisticated mechanical ventilation systems (such as increased air changes per hour, directional flow and filtration systems) had the lowest total bioaerosol concentrations (9 cfu/m³, 95% CI: 7-13). Operating sophisticated mechanical ventilation systems in hospitals contributes to improved indoor air quality within hospitals, which assists in reducing the risk of airborne transmission of HAIs.

Assessment of Airborne Bacterial and Fungal Communities in Selected Areas of Teaching Hospital, Kandy, Sri Lanka

Nosocomial infections, in lay term known as hospital acquired infections, are caused mainly by airborne pathogens found in healthcare facilities and their surroundings. The aim of this study was to quantify and identify bacteria and fungi in a hospital, which is an understudied area of air quality in Sri Lanka. Air samples were collected in agar medium and petri plates containing sterile filter papers. The number of culturable and total airborne microorganisms was estimated by manual counting and fluorescent microscopy, respectively. The morphologically distant bacteria and fungi were identified by DNA sequencing. The statistical analysis revealed significant variances between studied sites (p < 0.05) where Outpatients Department and Respiratory Unit showed higher levels of airborne microbial load. Culturable microbial count was higher at noon (hospital visiting hours) compared to other sampling periods (after hospital visiting hours) within the hospital. Total count of airborne microbes was found to be the highest during the afternoon. The most sensitive zones such as Operating Theatre and Intensive Care Unit showed considerably higher counts of airborne microbes. Identification by molecular means revealed the presence of human pathogens in the hospital air including Bacillus sp, Micrococcus sp, Pseudomonas sp, Staphylococcu ssp, Exiguobacterium sp, Enterobacter sp, Escherichia sp, Sphingomonas sp, Massilia sp, Kocuria sp, Fusarium sp, and Aspergillus sp. In conclusion, the results from this study indicate that the hospital air was generally contaminated. Therefore, the implementation of proactive policies and strategies are needed to monitor hospital air quality in sensitive zones as well as other areas of the hospitals.

The effect of temperature on airborne filamentous fungi in the indoor and outdoor space of a hospital

Fungi are one of the bioaerosols in indoor air of hospitals. They have adverse effects on staff and patients. The aim of this study was to investigate the effects of three incubation temperature on the density and composition of airborne fungi in an indoor and outdoor space of hospital. Sabouraud dextrose agar was used for culture the fungi. For improvement of aseptic properties, chloramphenicol was added to this medium. The density of airborne fungi was less than 282 CFU/m³. The highest density was detected in emergency room and the lowest of them was in neonatal intensive care unit (NICU) and operation room (OR). Results showed that fungi levels at 25 °C were higher than 37 and 15 °C (p = 0.006). In addition, ten different genera of fungi were identified in all departments. The predominant fungi were Fusarium spp., Penicillium spp., Paecilomyces spp., and Aspergillus niger. Moreover, the density and trend of distribution of Fusaruim spp. in the indoor space was directivity to outdoor space by ventilation system. The present study has provided that incubation temperature had effect on airborne fungi remarkably. We are suggested that more studies would be conducted on incubation temperature and other ambient factors on airborne fungi.

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

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

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

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

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

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

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

Molecular characterization of environmental Cladosporium species isolated from Iran

Background and Purpose:

Cladosporium species are ubiquitous, saprobic, dematiaceous fungi, only infrequently associated with human and animal opportunistic infections.

Materials and Methods:

Airborne samples were collected using the settle plate method, and soil samples were obtained from a depth of 5-10 cm of the superficial soil layer. Samples were cultured on Sabouraud dextrose agar (SDA) plates, incubated at 25°C, and examined daily for fungal colonies for two to three weeks. Isolates were identified as Cladosporium species according to the macroscopic and microscopic criteria. For species differentiation, DNA from 53 isolates was extracted and subjected to amplification of the internal transcribed spacer (ITS) region followed by sequencing.

Results:

A total of 270 samples were collected from various environmental sources, of which 79 strains of Cladosporium species were isolated. The most frequent species was C. cladosporioides (50.6%), followed by C. iridis (44.3%), C. elatum (2.5%), C. peranqestum (1.3%), and C. alicinum (1.3%).

Conclusion:

The collected data can serve as baseline information for future research and may be useful in the development of preventive and educational strategies.

Molecular characterization of environmental Cladosporium species isolated from Iran

Background and Purpose

Cladosporium species are ubiquitous, saprobic, dematiaceous fungi, only infrequently associated with human and animal opportunistic infections.

Materials and Methods

Airborne samples were collected using the settle plate method, and soil samples were obtained from a depth of 5-10 cm of the superficial soil layer. Samples were cultured on Sabouraud dextrose agar (SDA) plates, incubated at 25°C, and examined daily for fungal colonies for two to three weeks. Isolates were identified as Cladosporium species according to the macroscopic and microscopic criteria. For species differentiation, DNA from 53 isolates was extracted and subjected to amplification of the internal transcribed spacer (ITS) region followed by sequencing.

Results

A total of 270 samples were collected from various environmental sources, of which 79 strains of Cladosporium species were isolated. The most frequent species was C. cladosporioides (50.6%), followed by C. iridis (44.3%), C. elatum (2.5%), C. peranqestum (1.3%), and C. alicinum (1.3%).

Conclusion

The collected data can serve as baseline information for future research and may be useful in the development of preventive and educational strategies.

Real-time measurements of airborne biologic particles using fluorescent particle counter to evaluate microbial contamination: results of a comparative study in an operating theater

BACKGROUND

Airborne bacterial contamination poses a risk for surgical site infection, and routine surveillance of airborne bacteria is important. Traditional methods for detecting airborne bacteria are time consuming and strenuous. Measurement of biologic particle concentrations using a fluorescent particle counter is a novel method for evaluating air quality. The current study was to determine whether the number of biologic particles detected by the fluorescent particle counter can be used to indicate airborne bacterial counts in operating rooms.

METHODS

The study was performed in an operating theater at a university hospital in Hefei, China. The number of airborne biologic particles every minute was quantified using a fluorescent particle counter. Microbiologic air sampling was performed every 30 minutes using an Andersen air sampler (Pusong Electronic Instruments, Changzhou, China). Correlations between the 2 different methods were analyzed by Pearson correlation coefficients.

RESULTS

A significant correlation was observed between biologic particle and bacterial counts (Pearson correlation coefficient = 0.76), and the counting results from 2 methods both increased substantially between operations, corresponding with human movements in the operating room.

CONCLUSION

Fluorescent particle counters show potential as important tools for monitoring bacterial contamination in operating theatres.