Mold contamination in a controlled hospital environment: a 3-year surveillance in southern Italy

Data analysis of patients with positive mould or dimorphic fungal cultures from sterile sites

Background

Moulds and dimorphic fungi are increasingly recognised as pathogens carrying high morbidity and mortality in critically ill and immune-compromised patients. The lack of surveillance data limits our understanding of these infections.

Objectives

To determine the distribution, patient characteristics, risk factors, therapy and treatment outcome in patients with positive mould or dimorphic fungal cultures from sterile sites at a tertiary hospital in central South Africa.

Method

All moulds or dimorphic fungi cultured from sterile specimens from 1 July 2014 to 30 June 2017 were identified retrospectively. Laboratory and clinical records were reviewed. Information collected included gender and age, type of specimen collected for investigation, specific fungi isolated, underlying conditions, other contributing risk factors, treatment and outcome of the patients.

Results

Forty-eight patient records were analysed. Male and female patients were equally distributed. The mean age was 40.5 years (range 7-78 years). Aspergillus spp. were most commonly isolated. The most common underlying condition was HIV infection, followed by haematological conditions. Twenty-six (54.2%) patients received treatment involving antifungal therapy alone (n = 19; 73.1%), surgery alone (n = 5; 19.2%) or a combined medical and surgical approach (n = 2; 7.7%). Twenty-two (45.8%) patients received no treatment. The overall mortality rate was 25.0% (n = 12).

Conclusion

The diagnosis of fungal infections remains challenging. In the current study, moulds and dimorphic fungi were isolated from at-risk patients' specimens. Despite treatment with appropriate antifungal agents, the associated mortality rate was high.

Contribution

This study contributes to the growing body of knowledge on these potentially life-threatening infections.

Environmental monitoring for filamentous fungal pathogens in hematopoietic cell transplant units

The incidence of invasive fungal disease (IFD) is on the rise due to increasing numbers of highly immunocompromized patients. Nosocomial IFD remains common despite our better understanding of its risk factors and pathophysiology. High-efficiency particulate air filtration with or without laminar air flow, frequent air exchanges, a positive pressure care environment, and environmental hygiene, amongst other measures, have been shown to reduce the mould burden in the patient environment. Environmental monitoring for moulds in areas where high-risk patients are cared for, such as hematopoietic cell transplant units, has been considered an adjunct to other routine environmental precautions. As a collaborative effort between authors affiliated to the Infection Prevention and Control Working Group and the Fungal Infection Working Group of the International Society of Antimicrobial Chemotherapy (ISAC), we reviewed the English language literature and international guidance to describe the evidence behind the need for environmental monitoring for filamentous fungi as a quality assurance approach with an emphasis on required additional precautions during periods of construction. Many different clinical sampling approaches have been described for air, water, and surface sampling with significant variation in laboratory methodologies between reports. Importantly, there are no agreed-upon thresholds that correlate with an increase in the clinical risk of mould infections. We highlight important areas for future research to assure a safe environment for highly immunocompromized patients.

Relationship Between Airborne Fungi Presence and the Position of the High Efficiency Particulate Air Filter in the Heating, Ventilation, and Air Conditioning System

AIM

Establish the influence of the terminal or nonterminal position of High Efficiency Particulate Air (HEPA) filters in the Heating, Ventilation, and Air Conditioning (HVAC) system on the presence of airborne fungi in controlled environment rooms.

BACKGROUND

Fungal infections are an important cause of morbidity and mortality in hospitalized patients.

METHODS

This study was realized from 2010 to 2017, in rooms with terminal and nonterminal HEPA filters, in eight Spanish hospitals. In rooms with terminal HEPA filters, 2,053 and 2,049 samples were recollected, and in rooms with nonterminal HEPA filters, 430 and 428 samples were recollected in the air discharge outlet (Point 1) and in the center of the room (Point 2), respectively. Temperature, relative humidity, air changes per hour, and differential pressure were recollected.

RESULTS

Multivariable analysis showed higher odds ratio (OR) of airborne fungi presence when HEPA filters were in nonterminal position (OR: 6.78; 95% CI [3.77, 12.20]) in Point 1 and (OR: 4.43; 95% CI [2.65, 7.40]) in Point 2. Other parameters influenced airborne fungi presence, such as temperature (OR: 1.23; 95% CI [1.06, 1.41]) in Point 2 differential pressure (OR: 0.86; 95% CI [0.84, 0.90]) and (OR: 0.88; 95% CI [0.86, 0.91]) in Points 1 and 2, respectively.

CONCLUSIONS

HEPA filter in terminal position of the HVAC system reduces the presence of airborne fungi. To decrease the presence of airborne fungi, adequate maintenance of the environmental and design parameters is necessary in addition to the terminal position of the HEPA filter.

Evaluation of the Results of a Periodic Environmental Biosecurity Assessment Program on Air Quality in Controlled Environment Rooms of Hospitals

AIM

Determine the utility of the Periodic Environmental Biosecurity Assessment Program (PEBAP) in achieving clean air as measured by the number of colony-forming units (CFU) of fungi and bacteria in the air.

BACKGROUND

There is no international consensus on the sampling frequency, the recommended limits for microorganisms in the air nor on the usefulness of routine microbiological air monitoring of hospitals.

METHODS

During the PEBAP, data were recollected between 2010 and 2017 in eight hospitals in southeast Spain. Air samples were collected in very high risk rooms (VHRRs) and high risk rooms (HRRs), unoccupied, using active sampling methods. Temperature, relative humidity, air changes per hour (ACH), and differential pressure were measured. When limits of CFU of opportunistic fungi and bacteria established in the PEBAP were exceeded, corrective measures were adopted.

RESULTS

We found a reduction (p < .01) of percentage of air samples with fungi growth throughout the years of PEBAP in all rooms. Aspergillus was the most frequent opportunistic fungus. We found a high compliance of the standards of CFU of bacteria in HRR, and the percentage of compliance in VHRR was lower than in HRR in all years. Differences in environmental and design parameters were statistically significant (p < .05) between rooms, except for ACH.

CONCLUSIONS

PEBAP resulted in a useful tool to maintain and improve air quality in hospitals. The control of environmental biosecurity requires a multidisciplinary approach from preventive medicine, engineering, and cleaning services. Aspergillus is the most frequent opportunistic fungus in southeast Spain.

Epidemiology of Healthcare-Associated Infections and Adherence to the HAI Prevention Strategies

Healthcare-associated infections are widely considered one of the most common unfavorable outcomes of healthcare delivery. Ventilator-associated pneumonia, central line-associated bloodstream infections, and catheter-associated urinary tract infections are examples of healthcare-associated infections. The current study was a retrospective study conducted at a public hospital in Unaizah, Saudi Arabia, to investigate the frequency of healthcare-associated illnesses and adherence to healthcare-associated infection prevention techniques in the year 2021. Surgical site infections occurred at a rate of 0.1%. The average number of catheter-associated urinary tract infections per 1000 catheter days was 0.76. The average number of central line-associated bloodstream infections per 1000 central line days was 2.6. The rate of ventilator-associated pneumonia was 1.1 per 1000 ventilator days on average. The average number of infections caused by multidrug-resistant organisms per 1000 patient days was 2.8. Compliance rates were 94%, 100%, 99%, and 76% for ventilator-associated pneumonia, central line-associated bloodstream infections, catheter-associated urinary tract infections, and hand hygiene bundles, respectively. It is critical to participate in more educational events and workshops, particularly those that emphasize hand cleanliness and personal safety equipment.

Severe Recurrent COVID-Associated Pulmonary Aspergillosis: A Challenging Case

We report a rare case of severe COVID-19-associated pulmonary aspergillosis presenting as invasive pulmonary aspergillosis and subsequently invasive tracheobronchial aspergillosis during hospitalization in a critically ill patient who developed a further Aspergillus infection after home discharge. He needed readmission to the ICU and mechanical ventilation. We therefore strongly encourage a high degree of attention to fungal complications, even after viral recovery and ICU discharge.

Medication Errors in Intensive Care Units: An Umbrella Review of Control Measures

Medication errors are defined as “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer.” Such errors account for 30 to 50 percent of all errors in health care. The literature is replete with systematic reviews of medication errors, with a considerable number of studies focusing on systems and strategies to prevent errors in intensive care units, where these errors occur more frequently; however, to date, there appears to be no study that encapsulates and analyzes the various strategies. The aim of this study is to identify the main strategies and interventions for preventing medication errors in intensive care units through an umbrella review. The search was conducted on the following databases: PubMed, CINAHL, PsycInfo, Embase, and Scopus; it was completed in November 2020. Seven systematic reviews were included in this review, with a total of 47 studies selected. All reviews aimed to evaluate the effectiveness of a single intervention or a combination of interventions and strategies to prevent and reduce medication errors. Analysis of the results that emerged identified two macro-areas for the prevention of medication errors: systems and processes. In addition, the findings highlight the importance of adopting an integrated system of interventions in order to protect the system from harm and contain the negative consequences of errors.

Vaccine and Vaccination: On Field Research

Historically, vaccinations have enabled the eradication, elimination, and control of many debilitating diseases [...]

From Survey Results to a Decision-Making Matrix for Strategic Planning in Healthcare: The Case of Clinical Pathways

Background: It is a well-known fact that the information obtained from a survey can be used in a healthcare organizational analysis; however, it is very difficult to compare the different results found in the literature to each other, even through the use of metanalysis, as the methodology is often not consistent. Methods: Data from a survey analyzing the organizational and managerial responses adopted in pathology-specific clinical pathways (CPs) during the first two waves of the COVID-19 pandemic were used for constructing a decisional matrix, a tool called SPRIS system, consisting of four different sheets. The first sheet reports the results of the survey and, using a streetlight color system, identifies strengths and weaknesses; the second one, by assigning a priority score, establishes the priority of intervention on each of the strengths and weaknesses identified; the third sheet reports the subjective items of the questionnaire in order to identify threats and opportunities and their probability of happening; in the last sheet, a SWOT Analysis is used to calculate the performance index of the whole organization. Results: The SPRIS system, applied to data concerning the adaptation of four CPs to the COVID-19 pandemic, showed that, whereas all the CPs had a good performance index, some concerns remained unsolved and need be addressed. Conclusions: The SPRIS system showed to be an easily constructed tool that is able to give an overview of the organization analyzed by the survey and to produce an index that can be used in a direct quality comparison between different services or organizations.

Capturing the Features of Physical Activity in Old Adults during the COVID-19 Pandemic: Results of an Italian Survey

The restriction measures adopted to control the COVID-19 pandemic had significant consequences on individuals’ lifestyles. This study is aimed at assessing the amount and type of habitual physical activity (PA) in older adults during the advanced phase of the pandemic and their possible relationships with sociodemographic aspects. A questionnaire that included sociodemographic characteristics and the Physical Activity Scale for the Elderly (PASE) was administered online to elderly subjects living in the Apulia region, South Italy. A sample of 939 participants (57.1% F; mean age 75.9 ± 6.3) was obtained. In total, 68.8% of female respondents reported a decrease in PA during the pandemic, while 55.1% of men maintained their previous levels (<0.001). The total PASE score did not differ between gender groups (median value 91.7 in males vs. 90.0 in females; p = 0.067). However, differences were registered in leisure activities, particularly regarding walking (23.8 ± 14.8 in males vs. 20.2 ± 14.6 in females; p = 0.001). Higher PA levels were related with lower age (OR 0.253; 95% CI 0.192−0.333; p = 0.001). Since inactivity can affect elderly health and wellbeing, and considering the impact of the COVID-19 lockdown on this habit, health promotion strategies to counteract the negative effects of the pandemic should include interventions aimed at increasing PA in this sub-group of the population, especially among women and elderly subjects.

Investigations on the Efficacy of Ozone as an Environmental Sanitizer in Large Supermarkets

Awareness of the importance of the microbial contamination of air and surfaces has increased significantly during the COVID-19 pandemic. The aim of this study was to evaluate the presence of bacteria and fungi in the air and on surfaces within some critical areas of large supermarkets with and without an ozonation system. Surveys were conducted in four supermarkets belonging to the same commercial chain of an Apulian city in June 2021, of which two (A and B) were equipped with an ozonation system, and two (C and D) did not have any air-diffused remediation treatment. There was a statistically significant difference in the total bacterial count (TBC) and total fungal count (TFC) in the air between A/B and C/D supermarkets (p = 0.0042 and p = 0.0002, respectively). Regarding surfaces, a statistically significant difference in TBC emerged between A/B and C/D supermarkets (p = 0.0101). To the best of our knowledge, this is the first study evaluating the effect of ozone on commercial structures in Italy. Future investigations, supported by a multidisciplinary approach, will make it possible to deepen the knowledge on this method of sanitation, in light of any other epidemic/pandemic waves.

Medication Adherence in Chronic Older Patients: An Italian Observational Study Using Medication Adherence Report Scale (MARS-5I)

Background: the world population is aging, and the prevalence of chronic diseases is increasing. Chronic diseases affect the quality of life of patients and contribute toward increased healthcare costs if patients do not adhere to treatment. This study defines the medication adherence levels of patients with chronic diseases. Methods: an observational cross-sectional study was carried out. Patients aged 65 years and older with chronic diseases were included in this study. The medication adherence report scale was used. Results: overall, 98 patients aged 65 years and older were included. The mean age of responders was 78.65 years. Study population: 71.43% were always adherent; 9.79% often adherent; 14.89% sometimes adherent; 3.87% rarely adherent; and 1% never adherent. The internal consistency of the MARS-5I was good: Cronbach’s alfa value of 0.77. Conclusions: the MARS-5I is an effective self-report instrument to measure the medication adherence of patients. However, further studies are needed to explore factors affecting medication adherence to avoid clinical consequences for patients and high healthcare costs for healthcare facilities. Healthcare communication could be improved to ensure better transitional care.

No-Touch Automated Disinfection System Based on Hydrogen Peroxide and Ethyl Alcohol Aerosols for Use in Healthcare Environments

Healthcare-related infections are sustained by various bacteria and fungi. In recent years, various technologies have emerged for the sanitation of healthcare-related environments. This study evaluated the effectiveness of a no-touch disinfection system that aerosolizes 5% hydrogen peroxide and 10% ethyl alcohol. After selecting an environment, the Total Bacterial Count and the Total Fungal Count in the air and on a surface of the room were determined to evaluate the effectiveness of the aerosolization system. In addition, sterile stainless-steel plates inoculated with S. aureus, P. aeruginosa, and Aspergillus spp. isolated from hospitalized patients and reference strains were used to evaluate the effectiveness of the system. For each organism, three plates were used: A (cleaned), B (not cleaned), and C (control). The A plates were treated with non-ionic surfactant and the aerosolization system, the B plates were subjected to the aerosolization system, and the plates C were positioned outside the room that was sanitized. Following sanitization, air and surface sampling was conducted, after which, swabs were processed for bacterial and fungal enumeration. The results showed that the air sanitization system had good efficacy for both bacteria and fungi in the air and on stainless-steel plates, particularly for the A plates.

Impact of Fungal Spores on Asthma Prevalence and Hospitalization

Despite making up a significant proportion of airborne allergens, the relationship between fungal spores and asthma is not fully explored. Only 80 taxa of fungi have so far been observed to exacerbate respiratory presentations, with Cladosporium spp., Aspergillus spp., Penicillium spp., and Alternaria spp. found to comprise the predominant allergenic airborne spores. Fungal spores have been found in indoor environments, such as hospitals and housing due to poor ventilation. Meanwhile, outdoor fungal spores exhibit greater diversity, and higher abundance and have been associated with hospitalizations from acute asthma presentations. In addition, fungal spores may be the underlying, and perhaps the “missing link”, factor influencing the heightened rate of asthma presentations during epidemic thunderstorm asthma events. To improve our knowledge gap on fungal spores, airborne allergen monitoring must be improved to include not only dominant allergenic fungi but also provide real-time data to accurately and quickly warn the general public. Such data will help prevent future asthma exacerbations and thus save lives. In this review, we examine the health risks of prominent allergenic fungal taxa, the factors influencing spore dispersal and distribution, and why improvements should be made to current sampling methods for public health and wellbeing.

How do Vaccinators Experience the Pandemic? Lifestyle Behaviors in a Sample of Italian Public Health Workers during the COVID-19 Era

Public health workers (PHWs) have experienced substantial workload changes because of their role in managing measures to limit the spread of COVID-19. The study’s aim was to assess lifestyle changes in Italian PHWs during the pandemic. PHWs attending an annual meeting completed an anonymous questionnaire assessing their sociodemographic and behavioral characteristics and lifestyle changes during the pandemic. A total of 1000 questionnaires were completed. Most participants (63.5% women, mean age 40 ± 13.1 years) were of normal weight (61.5%), non-smokers (81.9%), had a total screen time of ≥5 h/day (83.1%), and slept at least 6 h/night (88.7%). Approximately one-third consumed sweet foods every day (30%) and did not engage in physical activity (34.6%). Current sweet food consumption, physical activity, and sleep were associated with changes in these behaviors in the last 2 years (Tau-b = 0.155; Tau-b = −0.175; Tau-b = −0.276, respectively, p < 0.001). An increase in remote working was associated with worse sleep (odds ratio (OR) 2.065, 95% confidence interval (CI) 1.482–2.877) and diet (OR 1.982, 95% CI 1.385–2.838), and increased tablet/PC use (OR 3.314, 95% CI 2.358–4.656). Health promotion measures are needed to support the adoption of healthy lifestyles in this population during the current pandemic.

Impact of the COVID-19 Pandemic on Clinical Pathways for Non-SARS-CoV-2 Related Diseases in the Lazio Region, Italy

Clinical pathways (CPs) are multidisciplinary clinical governance tools necessary for the care management of the patients, whose aim is to outline the best practicable path within a health organization related to an illness or to a complex clinical situation. The COVID-19 pandemic emergency has created the need for an organizational renewal of care pathways based on the principles of “primary health care” recommended by the WHO. In Italy, the Hospitals and Local Health Authorities (ASL) have tried to guarantee the continuity of non-deferrable treatments and the maximum safety of both patients and health professionals. This study analyzes the organizational and managerial responses adopted in pathology-specific care pathways to assess how CPs as diagnostic tools responded to the COVID-19 pandemic in the first two waves. Twenty-four referents of Operational Units (UU OO) from Hospitals (AO) and Local Health Authorities (ASL) of the Lazio Region (Central Italy) that apply four different CPs responded to a survey, which analyzes the managerial and organizational responses of CPs in regard to different contexts. Results show that the structural and organizational adjustments of the CPs have made it possible to maintain an adequate level of care for specific treatment processes, with some common critical aspects that require improvement actions. The adjustments found could be useful for dealing with new outbreaks and/or new epidemics in order to try to mitigate the potential negative impact, especially on the most vulnerable patient categories.

Do closed waste containers lead to less air contamination than opened? A clinical case study at Jena University Hospital, Germany

Nosocomial infections are a growing challenge at hospitals. This clinical study aimed to investigate the influence of waste container construction ((open (O), closed (C), and hands-free opening (HF)) on microbial air contamination in a hospital setting. The results are intended to help develop guidelines for waste containers for the collection of non-infectious waste at hospitals and medical facilities. The clinical experiment was conducted at the University Hospital Jena, Germany. Air Impactor samples were performed and microbiologically evaluated for bacteria and fungi both quantitatively and qualitatively. The results were statistically determined using generalized estimating equations. Quantitatively, the lowest bacterial counts in ambient air were found around closed waste containers (114.74 CFU/m³) in comparison to HF (129.28 CFU/m³) and O (126.28 CFU/m³). For fungi, the surrounding air of C (2.08 CFU/m³) and HF (1.97 CFU/m³) waste containers showed a lower impact of fungal air contamination than for O (2.32 CFU/m³). Overall, it was shown that C are more preferable to HF and O waste containers from the point of view of microbial air contamination at hospitals.

Microbiological Monitoring of the Environment Using the "Association Rules" Approach and Disinfection Procedure Evaluation in a Hospital Center in Morocco

Background

The hospital environment, especially surfaces and medical devices, is a source of contamination for patients.

Objective

This study carried out, to the best of our knowledge, for the first time at Taza Hospital in Morocco aimed to assess the microbiological quality of surfaces and medical devices in surgical departments and to evaluate the disinfection procedure in time and space.

Methods

Samples were taken by swabbing after cleaning the hospital surface or medical device, to isolate and identify germs which were inoculated on semiselective culture media then identified by standard biochemical and physiological tests, using the analytical profile index (API) galleries. Moreover, the association rules extraction model between sites on the one hand and germs on the other hand was used for sampling.

Results

The study showed that 83% of the samples have been contaminated after biocleaning. The most contaminated services have been men's and women's surgeries. 62% of isolated germs have been identified as Gram-positive bacteria, 29% as Gram-negative bacteria, and 9% as fungi. Concerning the association rules extraction model, a strong association between some contaminated sites and the presence of germ has been found, such as the association between wall and nightstand and door cuff, meaning that the wall and nightstand contamination is systematically linked to that of the door cuff. The disinfection procedure efficacy evaluation has enabled suggesting renewing it each 4 h.

Conclusion

Microbiological monitoring of surfaces is necessary at hospital level through the use of the association rule extraction model, which is very important to optimize the sampling, cleaning, and disinfection site scenarios of the most contaminated ones.

Microbial Air Quality in Healthcare Facilities

There is increasing evidence that indoor air quality and contaminated surfaces provide an important potential source for transmission of pathogens in hospitals. Airborne hospital microorganisms are apparently harmless to healthy people. Nevertheless, healthcare settings are characterized by different environmental critical conditions and high infective risk, mainly due to the compromised immunologic conditions of the patients that make them more vulnerable to infections. Thus, spread, survival and persistence of microbial communities are important factors in hospital environments affecting health of inpatients as well as of medical and nursing staff. In this paper, airborne and aerosolized microorganisms and their presence in hospital environments are taken into consideration, and the factors that collectively contribute to defining the infection risk in these facilities are illustrated.

[Biodiversity of isolated fungal flora at the reanimation service of the University Hospital Souro Sanou of Bobo-Dioulasso, Burkina Faso]

Introduction

les maladies nosocomiales demeurent un problème majeur de santé publique en Afrique subsaharienne notamment au Burkina Faso. Cette étude avait pour but de déterminer la biodiversité de la flore fongique identifiée au service de réanimation du Centre Hospitalier Universitaire Souro Sanou (CHUSS) de Bobo-Dioulasso.

Méthodes

l´étude transversale descriptive s´est déroulée d´août 2016 à janvier 2017. La flore fongique a été recherchée dans l´air ambiant et les espaces de réanimation. Les prélèvements ont été ensemencés et incubés pendant 3 à 4 jours à 37°C à l´étuve. L´identification des colonies fongiques était macroscopique et microscopique pour les champignons filamenteux. Le test de blastèse, les milieux chromogéniques et le test d´agglutination au latex ont servi à l´identification d´espèces de Candida.

Résultats

sur les 200 prélèvements collectés au total, 176 ont poussé sur la gélose Sabouraud-Chloramphénicol. La prévalence globale de la flore fongique était de 88% (176/200). Les moisissures étaient les agents fongiques majoritairement retrouvés (66,9%). Parmi les huit genres de moisissures identifiés, Aspergillus était le genre le plus représenté (48,9%) tandis qu´Aspergillus fumigatus était l´espèce la plus fréquemment rencontrée (32,9%).

Conclusion

la décontamination régulière des niches fongiques devraient être systématiques dans le service de réanimation du CHUSS de Bobo-Dioulasso.

Evaluation of Rhodotorula spp. contamination in hospital environments

Microbiological monitoring of air and surfaces is a valuable tool for assessing the level of environmental contamination by bacteria and fungi in hospitals, especially in high-risk wards. The presence of these microorganisms requires strict control in view of their role as opportunistic pathogens. As regard yeasts, Candida albicans is one of the main opportunistic pathogens. However, in recent years, many other "non-Albicans" species have been identified that are implicated in the onset of both localised infections in immunocompetent patients and systemic infections in immunocompromised patients. The aim of the work was to evaluate the frequency of isolation of Rhodotorula spp. in environmental samples of hospital origin in order to highlight how its presence may represent an increased risk for hospitalised patients. The samples were taken in at-risk wards, divided into six types of environments, in three hospitals in southern Sardinia between 2016 and 2019. The presence of moulds and yeasts was higher in the air (55.7%) than on surfaces (44.3%) in the hospital environments (p < 0.001). Similarly, the isolation frequency of Rhodotorula spp. was found to be greater (p < 0.001) in the air (14.2%) than on surfaces (9.2%). This study made it possible to evaluate the presence of pathogenic fungi in hospital environments, paying particular attention to Rhodotorula spp. since it is an emerging opportunistic yeast. It also highlights the importance of control measures especially in those where immunocompromised patients are present.

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

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

Evaluation of Air Contamination in Orthopaedic Operating Theatres in Hospitals in Southern Italy: The IMPACT Project

Postoperative infections are a concern, especially in total knee and total hip arthroplasty. We evaluated the air quality in orthopaedic operating theatres in southeastern Italy to determine the level of bacterial contamination as a risk factor for postoperative infection. Thirty-five hospitals with operating theatres focused on total knee and total hip arthroplasty participated. We sampled the air passively and actively before surgeries began for the day (at rest) and 15 min after the surgical incision (in operation). We evaluated bacterial counts, particle size, mixed vs turbulent airflow systems, the number of doors, number of door openings during procedures and number of people in the operating theatre. We found no bacterial contamination at rest for all sampling methods, and significantly different contamination levels at rest vs in operation. We found no association between the number of people in the surgical team and bacteria counts for both mixed and turbulent airflow systems, and low bacterial loads, even when doors were always open. Overall, the air quality sampling method and type of ventilation system did not affect air quality.

Air Quality and Employee Hygiene-related Behavior in a Post Anesthesia Care Unit in Thailand

Post anesthesia care units (PACU) are sanitary spaces at hospitals. Bacterial and fungal contaminants in ambient air can pose significant threats to patient recovery. Excess waste anesthetic gases such as nitrous oxide and desflurane can also pose reproductive, genetic, and other health risks to PACU staff who suffer longterm exposure. Healthcare institutions routinely monitor and study PACU air quality as required by occupational health and safety acts and related regulations, and professional standards of care. This study presents recent data from a PACU intervention at Rajavithi Hospital in Bangkok, Thailand. Rajavithi took measurements of concentrations of airborne fungi, bacteria, desflurane, and nitrous oxide before and after installation of a new ventilation system. Concurrently, the hospital surveyed employees before and after a hazard communication and conducted a training campaign in efforts to understand employee attitudes toward health and safety procedures, and to increase their perceived importance of several PACU-specific protocols. Results showed bacterial contamination fell from 1,307 CFU/m³ to 182 CFU/m³, fungi fell from 70.4 CFU/m³ to 35.8 CFU/m³, desflurane fell from 0.25 ppm to 0.21 ppm, and nitrous oxide fell from 21.86 ppm to 20.47 ppm during the intervention while PACU worker attitudes toward health and safety improved. Additional monitoring, communication, and training are recommended for Rajavithi and other healthcare institutions.

Air Quality and Employee Hygiene-related Behavior in a Post Anesthesia Care Unit in Thailand

Background:

Airborne contaminants in Postanesthesia Care Units (PACUs) such as bacteria, fungi, and waste anesthetic gases pose serious, and sometimes fatal, risks to both patients and PACU workers. Numerous studies have linked long-term exposure to nitrous oxide and halogenated agents to, among other things, reproductive problems in PACU nurses and anesthesiologists. Microorganism contamination can result in a post-surgical complication, to which patients with diabetes and other respiratory diseases are especially vulnerable. Various researchers and governmental agencies have recommended hospitals take steps to reduce levels of airborne contaminants in PACUs. In particular, hazard communication programs are recommended to inform and train staff on relevant occupational health and safety procedures. Additionally, and perhaps more importantly, experts recommend hospitals install specialized ventilation systems to maintain low levels of airborne pollutants.

Objective:

This study has two main parts: (1) measurement of airborne contaminants in the PACU at Rajavithi Hospital in Bangkok, Thailand; and (2) assessment of PACU workers’ perceived level of importance regarding occupational health and safety protocols,viaself-reporting survey. The study also has two main objectives: (1) to determine whether, and to what extent, a new ventilation system helps reduce airborne contaminants in the PACU; and (2) to discover whether an informational campaign increases perceived importance of health and safety procedures among PACU workers (i.e. handwashing, changing shoes, wearing proper facemasks).

Methods:

Surveys and air quality measurements were collected two times – in July 2016 and April 2017 – before and after Rajavithi Hospital implemented a hazard communication program consisting of training, posters, brochures, and informational media. Survey participants included all 64 PACU workers – 61 nurses and 3 anesthetists. Air sampling measured levels of bacteria, fungi, nitrous oxide, and desflurane.

Results:

Initial levels of airborne microorganisms were very high (1307CFU/m3for bacteria and 70.4 CFU/m3for fungi) and on the high end of normal for nitrous oxide (21.86ppm). Following the informational campaign and installation of the ventilation system, levels of bacterial contamination fell to 182 CFU/m3, and fungi fell to 35.8 CFU/m3. Simultaneously, workers’ levels of perceived importance for health and safety procedures increased.

Conclusion:

Both aspects of the study were successful, however, concentration of airborne microorganisms still exceeded recommended limits at the end of the study. Hospital administration and staff are encouraged to continue training and informing workers while assessing ventilation system until contamination levels fall to within internationally acceptable ranges.

Effects of indoor environmental parameters related to building heating, ventilation, and air conditioning systems on patients' medical outcomes: A review of scientific research on hospital buildings

The indoor environment of a mechanically ventilated hospital building controls infection rates as well as influences patients' healing processes and overall medical outcomes. This review covers the scientific research that has assessed patients' medical outcomes concerning at least one indoor environmental parameter related to building heating, ventilation, and air conditioning (HVAC) systems, such as indoor air temperature, relative humidity, and indoor air ventilation parameters. Research related to the naturally ventilated hospital buildings was outside the scope of this review article. After 1998, a total of 899 papers were identified that fit the inclusion criteria of this study. Of these, 176 papers have been included in this review to understand the relationship between the health outcomes of a patient and the indoor environment of a mechanically ventilated hospital building. The purpose of this literature review was to summarize how indoor environmental parameters related to mechanical ventilation systems of a hospital building are impacting patients. This review suggests that there is a need for future interdisciplinary collaborative research to quantify the optimum range for HVAC parameters considering airborne exposures and patients' positive medical outcomes.

Microbiological Air Quality in Heating, Ventilation and Air Conditioning Systems of Surgical and Intensive Care Areas: The Application of a Disinfection Procedure for Dehumidification Devices

International literature data report that the increase of infectious risk may be due to heating, ventilation and air conditioning (HVAC) systems contaminated by airborne pathogens. Moreover, the presence of complex rotating dehumidification wheels (RDWs) may complicate the cleaning and disinfection procedures of the HVAC systems. We evaluated the efficacy of a disinfection strategy applied to the RDW of two hospitals’ HVAC systems. Hospitals have four RDW systems related to the surgical areas (SA1 and SA2) and to the intensive and sub-intensive care (IC and sIC) units. Microbiological air and surface analyses were performed in HVAC systems, before and after the disinfection treatment. Hydrogen peroxide (12%) with silver ions (10 mg/L) was aerosolized in all the air sampling points, located close to the RDW device. After the air disinfection procedure, reductions of total microbial counts at 22 °C and molds were achieved in SA2 and IC HVAC systems. An Aspergillus fumigatus contamination (6 CFU/500 L), detected in one air sample collected in the IC HVAC system, was eradicated after the disinfection. The surface samples proved to be of good microbiological quality. The results suggest the need for a disinfection procedure to improve the microbiological quality of the complex HVAC systems, mostly in surgical and intensive care areas.

Study on the relationship between the concentration and type of fungal bio-aerosols at indoor and outdoor air in the Children's Medical Center, Tehran, Iran

Fungal bio-aerosols are of concern due to their adverse health effects, especially in indoor environments. The aim of this study was to evaluate the relationship between the concentration and type of fungal bio-aerosols in the indoor and outdoor of Children's Medical Center in Tehran, Iran. In the present descriptive-analytical study, the fungal bio-aerosols' concentrations in both indoor and outdoor of the hospital air were measured. The measurements were carried out by the Anderson method using a Quick Take 30 pump at 28.3 L min^-1 and 2.5 min sampling that was placed on a Sabouraud dextrose agar with chloramphenicol. The average concentrations of total fungal bio-aerosols in the hospital indoor and outdoor air were 40.48 and 119.6 CFU/m³, respectively. Onco-hematology and bone marrow transplantation wards were the most and least contaminated units, respectively (11.09 CFU/m³ vs 1.47 CFU/m³). The most common fungi isolated from the indoor environment were Penicillium spp. (45.86%) which was followed by Cladosporium spp. (31.92%), Aspergillus section Nigri (6.26%), sterilized mycelia (5.05%), and Aspergillus section Flavi (2.83%). Cladosporium spp. (61.10 CFU/m³) and Penicillium spp. (18.56 CFU/m³) had the highest mean concentrations in outdoor and indoor air, respectively. The indoor-to-outdoor ratio of fungal aerosols was < 1 at most sampling sites, indicating that the indoor fungal bio-aerosols may have originated from the outdoor environment.

Chronic postcataract endophthalmitis caused by Penicillium species in an immunocompetent patient

Objective

Penicillium species are abundant, generally saprophytic, and widely distributed in the environment. On rare occasions, they cause endophthalmitis in immunocompromised patients or in immunocompetent patients with uncontrolled diabetic mellitus or immunosuppressive agents. We report a case of endophthalmitis caused by Penicillium species in an immunocompetent patient without any disorders.

Case presentation

A 67-year-old woman presented with ocular pain, hyperemia, and blurred vision in her right eye. She was in an immunocompetent condition and had received cataract surgery without complications 3 months ago. Severe cell infiltration and a clump of 3 mm diameter were found in the anterior chamber of the right eye, and there was no abnormality in the posterior segment. Serum β-d-glucan was not elevated; bacterial culture, histological analysis, and PCR using aqueous humor did not detect any pathogen (28S rDNA 2.4×10² copies/mL). However, because the clinical findings suggested fungal endophthalmitis, anti-fungal medication was initiated. The inflammation was gradually resolved with contraction of the clump; however, it recurred 47 days after the initiation by discontinuation of antifungal medication. Examination of culture identified Penicillium species in samples from both the anterior chamber and the vitreous.

Conclusion

Chronic postoperative endophthalmitis by Penicillium species can occur in an immunocompetent patient without any systemic diseases.

Airborne fungi in an intensive care unit

The presence of airborne fungi in Intensive Care Unit (ICUs) is associated with increased nosocomial infections. The aim of this study was the isolation and identification of airborne fungi presented in an ICU from the University Hospital of Pelotas - RS, with the attempt to know the place's environmental microbiota. 40 Petri plates with Sabouraud Dextrose Agar were exposed to an environment of an ICU, where samples were collected in strategic places during morning and afternoon periods for ten days. Seven fungi genera were identified: Penicillium spp. (15.18%), genus with the higher frequency, followed by Aspergillus spp., Cladosporium spp., Fusarium spp., Paecelomyces spp., Curvularia spp., Alternaria spp., Zygomycetes and sterile mycelium. The most predominant fungi genus were Aspergillus spp. (13.92%) in the morning and Cladosporium spp. (13.92%) in the afternoon. Due to their involvement in different diseases, the identified fungi genera can be classified as potential pathogens of inpatients. These results reinforce the need of monitoring the environmental microorganisms with high frequency and efficiently in health institutions.

Indoor airborne fungal pollution in newborn units in Turkey

Pathogenic and/or opportunistic fungal species are major causes of nosocomial infections, especially in controlled environments where immunocompromised patients are hospitalized. Indoor fungal contamination in hospital air is associated with a wide range of adverse health effects. Regular determination of fungal spore counts in controlled hospital environments may help reduce the risk of fungal infections. Because infants have inchoate immune systems, they are given immunocompromised patient status. The aim of the present study was to evaluate culturable airborne fungi in the air of hospital newborn units in the Thrace, Marmara, Aegean, and Central Anatolia regions of Turkey. A total of 108 air samples were collected seasonally from newborn units in July 2012, October 2012, January 2013, and April 2013 by using an air sampler and dichloran 18% glycerol agar (DG18) as isolation media. We obtained 2593 fungal colonies comprising 370 fungal isolates representing 109 species of 28 genera, which were identified through multi-loci gene sequencing. Penicillium, Aspergillus, Cladosporium, Talaromyces, and Alternaria were the most abundant genera identified (35.14, 25.40, 17.57, 2.70, and 6.22% of the total, respectively).

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.

Longitudinal Metagenomic Analysis of Hospital Air Identifies Clinically Relevant Microbes

We describe the sampling of sixty-three uncultured hospital air samples collected over a six-month period and analysis using shotgun metagenomic sequencing. Our primary goals were to determine the longitudinal metagenomic variability of this environment, identify and characterize genomes of potential pathogens and determine whether they are atypical to the hospital airborne metagenome. Air samples were collected from eight locations which included patient wards, the main lobby and outside. The resulting DNA libraries produced 972 million sequences representing 51 gigabases. Hierarchical clustering of samples by the most abundant 50 microbial orders generated three major nodes which primarily clustered by type of location. Because the indoor locations were longitudinally consistent, episodic relative increases in microbial genomic signatures related to the opportunistic pathogens Aspergillus, Penicillium and Stenotrophomonas were identified as outliers at specific locations. Further analysis of microbial reads specific for Stenotrophomonas maltophilia indicated homology to a sequenced multi-drug resistant clinical strain and we observed broad sequence coverage of resistance genes. We demonstrate that a shotgun metagenomic sequencing approach can be used to characterize the resistance determinants of pathogen genomes that are uncharacteristic for an otherwise consistent hospital air microbial metagenomic profile.