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Abd El-Baky RM, Shady ER, Yahia R, Ahmed FY, Ramadan M, Ahmed HR, Al-Kadmy IMS, Ramadan YN, Hetta HF. COVID-19 associated Mucormycosis among ICU patients: risk factors, control, and challenges. AMB Express 2023; 13:99. [PMID: 37736777 PMCID: PMC10516834 DOI: 10.1186/s13568-023-01599-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 08/24/2023] [Indexed: 09/23/2023] Open
Abstract
The severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) pandemic is still difficult to be controlled. The spread of this virus and the emergence of new variants are considered a great challenge worldwide. Disturbance in infection control guidelines implementation, use of steroids, antibiotics, hospital crowdedness, and repeated use of oxygen masks during the management of critically ill COVID-19 patients lead to an increase in the rate of opportunistic infections. So, patients need to fight both the virus with its different variants and opportunistic pathogens including bacteria and fungi especially patients with diabetes mellitus, malignancy, or those who undergo hemodialysis and receive deferoxamine. During the pandemic, many cases of Mucormycosis associated with COVID-19 infection were observed in many countries. In this review, we discuss risk factors that increase the chance of infection by opportunistic pathogens, especially fungal pathogens, recent challenges, and control measures.
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Affiliation(s)
- Rehab Mahmoud Abd El-Baky
- Department of Microbiology and Immunology, Faculty of Pharmacy, Minia University, Minia, 61519, Egypt.
- Department of Microbiology and Immunology, Faculty of Pharmacy, Deraya University, Minia, 11566, Egypt.
| | - Esraa R Shady
- Department of Microbiology and Immunology, Faculty of Pharmacy, Deraya University, Minia, 11566, Egypt
| | - Ramadan Yahia
- Department of Microbiology and Immunology, Faculty of Pharmacy, Deraya University, Minia, 11566, Egypt
| | - Fatma Y Ahmed
- Department of Microbiology and Immunology, Faculty of Pharmacy, Minia University, Minia, 61519, Egypt
| | - Mohamed Ramadan
- Department of Microbiology and Immunology, Faculty of Pharmacy, Minia University, Minia, 61519, Egypt
| | - Hala Rady Ahmed
- Department of Microbiology and Immunology, Faculty of Pharmacy, Minia University, Minia, 61519, Egypt
| | - Israa M S Al-Kadmy
- Branch of Biotechnology, Department of Biology, College of Science, Mustansiriyah University, POX 10244, Baghdad, Iraq
| | - Yasmin N Ramadan
- Department of Microbiology and Immunology, Faculty of Pharmacy, Assiut University, Assiut, 71515, Egypt.
| | - Helal F Hetta
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Assiut University, Assiut, 71515, Egypt.
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Pham D, Howard-Jones AR, Sparks R, Stefani M, Sivalingam V, Halliday CL, Beardsley J, Chen SCA. Epidemiology, Modern Diagnostics, and the Management of Mucorales Infections. J Fungi (Basel) 2023; 9:659. [PMID: 37367595 DOI: 10.3390/jof9060659] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 06/08/2023] [Accepted: 06/10/2023] [Indexed: 06/28/2023] Open
Abstract
Mucormycosis is an uncommon, yet deadly invasive fungal infection caused by the Mucorales moulds. These pathogens are a WHO-assigned high-priority pathogen group, as mucormycosis incidence is increasing, and there is unacceptably high mortality with current antifungal therapies. Current diagnostic methods have inadequate sensitivity and specificity and may have issues with accessibility or turnaround time. Patients with diabetes mellitus and immune compromise are predisposed to infection with these environmental fungi, but COVID-19 has established itself as a new risk factor. Mucorales also cause healthcare-associated outbreaks, and clusters associated with natural disasters have also been identified. Robust epidemiological surveillance into burden of disease, at-risk populations, and emerging pathogens is required. Emerging serological and molecular techniques may offer a faster route to diagnosis, while newly developed antifungal agents show promise in preliminary studies. Equitable access to these emerging diagnostic techniques and antifungal therapies will be key in identifying and treating mucormycosis, as delayed initiation of therapy is associated with higher mortality.
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Affiliation(s)
- David Pham
- Centre for Infectious Diseases & Microbiology, Westmead Hospital, Westmead, NSW 2170, Australia
| | - Annaleise R Howard-Jones
- Centre for Infectious Diseases & Microbiology Laboratory Services, NSW Health Pathology-Institute of Clinical Pathology & Medical Research, Westmead Hospital, Westmead, NSW 2170, Australia
- Faculty of Medicine & Health, University of Sydney, Camperdown, NSW 2006, Australia
- Sydney Institute for Infectious Diseases, University of Sydney, Sydney, NSW 2006, Australia
| | - Rebecca Sparks
- Douglass Hanly Moir Pathology, Sydney, NSW 2113, Australia
| | - Maurizio Stefani
- Centre for Infectious Diseases & Microbiology Laboratory Services, NSW Health Pathology-Institute of Clinical Pathology & Medical Research, Westmead Hospital, Westmead, NSW 2170, Australia
| | - Varsha Sivalingam
- Centre for Infectious Diseases & Microbiology Laboratory Services, NSW Health Pathology-Institute of Clinical Pathology & Medical Research, Westmead Hospital, Westmead, NSW 2170, Australia
| | - Catriona L Halliday
- Centre for Infectious Diseases & Microbiology Laboratory Services, NSW Health Pathology-Institute of Clinical Pathology & Medical Research, Westmead Hospital, Westmead, NSW 2170, Australia
| | - Justin Beardsley
- Centre for Infectious Diseases & Microbiology, Westmead Hospital, Westmead, NSW 2170, Australia
- Faculty of Medicine & Health, University of Sydney, Camperdown, NSW 2006, Australia
- Sydney Institute for Infectious Diseases, University of Sydney, Sydney, NSW 2006, Australia
- Westmead Institute for Medical Research, Sydney, NSW 2145, Australia
| | - Sharon C-A Chen
- Centre for Infectious Diseases & Microbiology Laboratory Services, NSW Health Pathology-Institute of Clinical Pathology & Medical Research, Westmead Hospital, Westmead, NSW 2170, Australia
- Faculty of Medicine & Health, University of Sydney, Camperdown, NSW 2006, Australia
- Sydney Institute for Infectious Diseases, University of Sydney, Sydney, NSW 2006, Australia
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3
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Dang J, Goel P, Choi KJ, Massenzio E, Landau MJ, Pham CH, Huang S, Yenikomshian HA, Spellberg B, Gillenwater TJ. Mucormycosis following burn injuries: A systematic review. Burns 2023; 49:15-25. [PMID: 35842270 DOI: 10.1016/j.burns.2022.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 09/16/2021] [Accepted: 05/09/2022] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Mucormycosis is an opportunistic fungal infection with a high mortality rate. Though typically associated with diabetes and other conditions that affect innate immune function, infections can also be precipitated by conditions such as trauma and burns. Burn patients are particularly susceptible to fungal infections due to the immune dysfunction that often accompany their wounds. Indeed case series have described mucormycosis to occur in patients with burn injuries, however the factors contributing to mortality have not been well described. Thus, the purpose of our review was to identify factors contributing to morbidity and mortality in burn patients with Mucormycosis. METHODS A systematic review of the literature of mucormycosis infection in burn injury patients was performed on Pubmed and Google Scholar using the keywords: Mucor, Mucorales, Mucormycosis, Mucormycotina, Zygomycosis and burn or thermal injury. Clinical trials, observational studies, case reports, and case reviews were included if they provided information regarding mortality in adult and pediatric burn patients diagnosed with mucormycosis, review articles, non-English articles, and articles without patient information were excluded. No time limit was placed on our review. Individual patient data was stratified based on mortality. Statistical analysis was performed to investigate the relationship between patient risk factors and mortality, and the Oxford Level of Evidence was used to evaluate study quality. RESULTS 46 articles were included in our final review, encompassing 114 patients. On average, survivors had a total body surface area (TBSA)% of 46 (SD 19.8) while non-survivors had a TBSA of 65% (SD 16.4), and this difference was significant (p < .001). Patients with disseminated mucormycosis experienced an 80% mortality rate compared to 36% mortality rate in patients with localized disease (p < .001). We found no statistically significant difference in mean age (p > .05), diabetes (p > .05), mean delay in diagnosis (p > .05), time to antifungal therapy (p > .05), or type of therapy used (p > .05) between survivors and non-survivors. Our review was limited by the lack of prospective, controlled trials; thus, our review primarily consists of case reports. CONCLUSION Disseminated infections and higher TBSA both increased the risk of mortality in burn patients with mucormycosis, while diabetes did not increase mortality risk. The severity of the initial injury and infection locations must be taken into consideration to inform patient prognosis.
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Affiliation(s)
- Justin Dang
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States; Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, United States
| | - Pedram Goel
- Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Katherine J Choi
- Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Erik Massenzio
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, United States
| | - Mark J Landau
- Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Christopher H Pham
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Samantha Huang
- Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Haig A Yenikomshian
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States; Los Angeles County + University of Southern California (LAC+USC) Medical Center, Los Angeles, CA, United States
| | - Brad Spellberg
- Los Angeles County + University of Southern California (LAC+USC) Medical Center, Los Angeles, CA, United States; Division of Infectious Diseases, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - T Justin Gillenwater
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States; Los Angeles County + University of Southern California (LAC+USC) Medical Center, Los Angeles, CA, United States.
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Kathirvel S, Muthu V, Rudramurthy SM, Kaur H, Chakrabarti A, Agarwal R. Could cattle dung burning have contributed to the epidemic of COVID-19-associated mucormycosis in India? Results of an experimental aero-mycological study. Mycoses 2022; 65:1024-1029. [PMID: 35726395 PMCID: PMC9350001 DOI: 10.1111/myc.13487] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 06/11/2022] [Accepted: 06/15/2022] [Indexed: 11/30/2022]
Abstract
Background Several hypotheses have been proposed for explaining the outbreak of coronavirus disease 2019 (COVID‐19)‐associated mucormycosis in India, including the burning of cattle dung cakes, though no study has yet been conducted to support this claim. Methods We conducted an aero‐mycological study to evaluate whether Mucorales in the air increased during or after burning cattle dung cakes. We further compared the growth of Mucorales in the indoor air samples from houses with and without cattle. We also cultured fresh and dried cattle dung and soil samples for Mucorales. Results We noted no significant difference in the proportion of air samples growing Mucorales during (4/22 [18.2%]) and after (3/2 [13.6%]) cattle dung burning than that collected immediately before (4/22 [18.2%]). Mucorales were isolated in 15.4% of the indoor air samples obtained from different houses (both rural and urban); the proportion of samples growing Mucorales was not significantly different in households with and without cattle. We also observed growth of Mucorales in 6 of the 8 [75%] fresh and 3 of the 6 [50%] dried dung samples. The most common Mucorales isolated from soil and dung samples was Lichtheimia corymbifera, while Rhizopus arrhizus was the most common species isolated from indoor air samples. Conclusions We found no significant increase in the proportion of air samples growing Mucorales during or after burning cattle dung cake than that before. It seems unlikely that cattle dung burning contributes to the occurrence of mucormycosis.
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Affiliation(s)
- Soundappan Kathirvel
- Department of Community Medicine and School of Public Health, Postgraduate institute of medical education and Research, Chandigarh, India
| | - Valliappan Muthu
- Department of Pulmonary Medicine, Postgraduate institute of medical education and Research, Chandigarh, India
| | | | - Harsimran Kaur
- Department of Medical Microbiology, Postgraduate institute of medical education and Research, Chandigarh, India
| | - Arunaloke Chakrabarti
- Department of Medical Microbiology, Postgraduate institute of medical education and Research, Chandigarh, India
| | - Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate institute of medical education and Research, Chandigarh, India
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5
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Littlehales E, Teague R, Andrew D, Yassaie E. Mucormycosis in burns: a review. J Burn Care Res 2021; 43:353-360. [PMID: 34874443 DOI: 10.1093/jbcr/irab236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Mucormycosis is a rare fungal infection with a high mortality rate. It presents with scattered black/necrotic ulcers, white fungal elements, and progression of wounds despite seemingly adequate debridement. Diagnosis is confirmed on wound histology, however this is often delayed. There is currently no comprehensive review of burn related mucormycosis within the literature, making this the first paper to provide evidence-based treatment guidance. We performed a review of publications from 1946 - present. There were 151 cases of mucormycosis complicating burns. The mortality rate was 54.5%, and there was a significant increase in mortality with axial body site involvement compared with isolated peripheral involvement. The standard treatment was prompt and radical debridement. Utilisation of frozen section to guide debridement aided in clinical decision making. No systemic treatment reached statistical significance, however amphotericin B trended towards significance. Although there is no strong evidence for topical amphotericin B or hyperbaric oxygen, there may be benefit in some cases. This study recommends early radical debridement in conjunction with the European Confederation of Medical Mycology guidelines of IV liposomal/lipid complex amphotericin B >5mg/kg/day, with posaconazole 800mg daily in divided doses as a salvage or oral step-down 1.
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6
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Bernatchez SF, Schommer K. Infection prevention practices and the use of medical tapes. Am J Infect Control 2021; 49:1177-1182. [PMID: 33766550 DOI: 10.1016/j.ajic.2021.03.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 03/12/2021] [Accepted: 03/13/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Medical tapes are ubiquitous in healthcare and there are currently no guidelines for their storage and use. Tapes cannot be cleaned or disinfected; yet, several clinicians may use a given roll for any number of patients. Reports of tape contamination associated with clinical infection have been published. PURPOSE We reviewed the literature reporting microbiological studies, case reports of infections, and nosocomial outbreaks associated with the use of medical tapes and other adhesive devices to assess the prevalence of this problem. METHODS We conducted a literature search for cross-contamination due to medical tape use in 6 databases in June 2020 using indexing terms for surgical tape, adhesive agent, adhesives or the keyword for tape. We compiled available evidence on tape contamination as a cause for healthcare-associated infections (HAIs). MAIN FINDINGS Forty-two publications reported relevant microbiological studies, case reports of infections, and/or nosocomial outbreaks. Results demonstrated that tape rolls handled with questionable practices can harbor pathogens. Some studies showed the association between contaminated tape and HAIs, which in some cases even led to death. CONCLUSIONS The time has come to establish national guidelines to help reduce the risk of cross-contamination from medical tapes. We offer suggested elements for these guidelines. The COVID-19 pandemic brings greater scrutiny to eliminate any avoidable cause of infection transmission.
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7
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Shah KM, West C, Simpson J, Rainwater YB. Cutaneous mucormycosis following COVID-19 vaccination in a patient with bullous pemphigoid. JAAD Case Rep 2021; 15:80-81. [PMID: 34222572 PMCID: PMC8233544 DOI: 10.1016/j.jdcr.2021.06.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- Kishan M Shah
- Department of Dermatology, UT Southwestern Medical Center, Dallas, Texas
| | - Cameron West
- ProPath, Dermatopathology Division, Dallas, Texas
| | | | - Yevgeniya B Rainwater
- Department of Dermatology, UT Southwestern Medical Center, Dallas, Texas.,ProPath, Dermatopathology Division, Dallas, Texas
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8
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Nguyen MH, Kaul D, Muto C, Cheng SJ, Richter RA, Bruno VM, Liu G, Beyhan S, Sundermann AJ, Mounaud S, Pasculle AW, Nierman WC, Driscoll E, Cumbie R, Clancy CJ, Dupont CL. Genetic diversity of clinical and environmental Mucorales isolates obtained from an investigation of mucormycosis cases among solid organ transplant recipients. Microb Genom 2020; 6:mgen000473. [PMID: 33245689 PMCID: PMC8116672 DOI: 10.1099/mgen.0.000473] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 10/27/2020] [Indexed: 12/20/2022] Open
Abstract
Mucormycoses are invasive infections by Rhizopus species and other Mucorales. Over 10 months, four solid organ transplant (SOT) recipients at our centre developed mucormycosis due to Rhizopus microsporus (n=2), R. arrhizus (n=1) or Lichtheimia corymbifera (n=1), at a median 31.5 days (range: 13-34) post-admission. We performed whole genome sequencing (WGS) on 72 Mucorales isolates (45 R. arrhizus, 19 R. delemar, six R. microsporus, two Lichtheimia species) from these patients, from five patients with community-acquired mucormycosis, and from hospital and regional environments. Isolates were compared by core protein phylogeny and global genomic features, including genome size, guanine-cytosine percentages, shared protein families and paralogue expansions. Patient isolates fell into six core phylogenetic lineages (clades). Phylogenetic and genomic similarities of R. microsporus isolates recovered 7 months apart from two SOT recipients in adjoining hospitals suggested a potential common source exposure. However, isolates from other patients and environmental sites had unique genomes. Many isolates that were indistinguishable by core phylogeny were distinct by one or more global genomic comparisons. Certain clades were recovered throughout the study period, whereas others were found at particular time points. In conclusion, mucormycosis cases could not be genetically linked to a definitive environmental source. Comprehensive genomic analyses eliminated false associations between Mucorales isolates that would have been assigned using core phylogenetic or less extensive genomic comparisons. The genomic diversity of Mucorales mandates that multiple isolates from individual patients and environmental sites undergo WGS during epidemiological investigations. However, exhaustive surveillance of fungal populations in a hospital and surrounding community is probably infeasible.
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Affiliation(s)
- M. Hong Nguyen
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Carlene Muto
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Present address: Department of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Shaoji J. Cheng
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | | | - Guojun Liu
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | - Alexander J. Sundermann
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | | | - A. William Pasculle
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Eileen Driscoll
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Richard Cumbie
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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9
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Lago K, Decker CF, Chung KK, Blyth D. Difficult to Treat Infections in the Burn Patient. Surg Infect (Larchmt) 2020; 22:95-102. [PMID: 32466741 DOI: 10.1089/sur.2020.128] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background: Unusual infections can lead to complications in more severely burned patients and pose major challenges in treatment. Methods: The published literature of retrospective reviews and case series of the uncommon infections of osteomyelitis, polymicrobial bacteremia, recurrent bacteremia, endocarditis, central nervous system (CNS), and rare fungal infections in burned patients have been summarized and presented. Results: When compared with infections occurring in the non-burn population, these infections in burn patients are more likely to be because of gram-negative bacteria or fungi. Because of hyperdynamic physiology and changes in immunomodulatory response secondary to burns, the clinical presentation of these infections in a patient with major burns differs from that of the non-burn patient and may not be identified until the post-mortem examination. Some of these infections (osteomyelitis, endocarditis, CNS, rare fungal infections) may necessitate surgical intervention in addition to antimicrobial therapy to achieve cure. The presence of the burn and allograft can also present unique challenges for surgical management. Conclusions: These difficult and unusual infections in the severely burned patient necessitate an index of suspicion, appropriate diagnosis, identification and sensitivities of the putative pathogen, effective systemic antimicrobial therapy, and appropriate surgical intervention if recovery is to be achieved.
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Affiliation(s)
- Kathryn Lago
- Brooke Army Medical Center, Fort Sam Houston, Texas, USA
| | - Catherine F Decker
- Walter Reed National Military Medical Center, Bethesda, Maryland, USA.,Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Kevin K Chung
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Dana Blyth
- Walter Reed National Military Medical Center, Bethesda, Maryland, USA
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10
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Giacobbe DR, Riccardi N, Vena A, Bassetti M. Mould Infections of Traumatic Wounds: A Brief Narrative Review. Infect Dis Ther 2020; 9:1-15. [PMID: 32072492 PMCID: PMC7054562 DOI: 10.1007/s40121-020-00284-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Indexed: 01/06/2023] Open
Abstract
Mould infections may follow traumatic injuries, with direct fungal inoculum in the site of injury and subsequent angioinvasion, possibly resulting in tissue necrosis and systemic dissemination. The pathogenesis of mould infections following trauma injuries presents unique features compared with classical mould infections occurring in neutropenic or diabetic patients, because a large fraction of post-traumatic mould infections is observed in previously healthy individuals. Most of the published clinical experience and research on mould infections following traumatic injuries regards soldiers and infections after natural disasters. However, following trauma and soil contamination (e.g., agricultural or automotive injuries) other immunocompetent individuals may develop mould infections. In these cases, delays in correct diagnosis and treatment may occur if pertinent signs such as necrosis and absent or reduced response to antibacterial therapy are not promptly recognized. Awareness of mould infections in at-risk populations is needed to rapidly start adequate laboratory workflow and early antifungal therapy in rapidly evolving cases to improve treatment success and reduce mortality.
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Affiliation(s)
- Daniele Roberto Giacobbe
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy. .,Clinica Malattie Infettive, Ospedale Policlinico San Martino, IRCCS, Genoa, Italy.
| | - Niccolò Riccardi
- Department of Infectious, Tropical Diseases and Microbiology, IRCCS Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, Verona, Italy
| | - Antonio Vena
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy.,Clinica Malattie Infettive, Ospedale Policlinico San Martino, IRCCS, Genoa, Italy
| | - Matteo Bassetti
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy.,Clinica Malattie Infettive, Ospedale Policlinico San Martino, IRCCS, Genoa, Italy
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11
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Outbreaks of Mucorales and the Species Involved. Mycopathologia 2019; 185:765-781. [PMID: 31734800 DOI: 10.1007/s11046-019-00403-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 10/22/2019] [Indexed: 01/27/2023]
Abstract
The order Mucorales is an ancient group of fungi classified in the subphylum Mucoromycotina. Mucorales are mainly fast-growing saprotrophs that belong to the first colonizers of diverse organic materials and represent a permanent part of the human environment. Several species are able to cause human infections (mucormycoses) predominantly in patients with impaired immune system, diabetes, or deep trauma. In this review, we compiled 32 reports on community- and hospital-acquired outbreaks caused by Mucorales. The most common source of mucoralean outbreaks was contaminated medical devices that are responsible for 40.7% of the outbreaks followed by contaminated air (31.3%), traumatic inoculation of soil or foreign bodies (9.4%), and the contact (6.2%) or the ingestion (6.2%) of contaminated plant material. The most prevalent species were Rhizopus arrhizus and R. microsporus causing 57% of the outbreaks. The genus Rhizomucor was dominating in outbreaks related to contaminated air while outbreaks of Lichtheimia species and Mucor circinelloides were transmitted by direct contact. Outbreaks with the involvement of several species are reported. Subtyping of strains revealed clonality in two outbreaks and no close relation in two other outbreaks. Based on the existing data, outbreaks of Mucorales can be caused by heterogeneous sources consisting of different strains or different species. Person-to-person transmission cannot be excluded because Mucorales can sporulate on wounds. For a better understanding and prevention of outbreaks, we need to increase our knowledge on the physiology, ecology, and population structure of outbreak causing species and more subtyping data.
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12
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A Guide to Investigating Suspected Outbreaks of Mucormycosis in Healthcare. J Fungi (Basel) 2019; 5:jof5030069. [PMID: 31344775 PMCID: PMC6787571 DOI: 10.3390/jof5030069] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 07/04/2019] [Accepted: 07/17/2019] [Indexed: 12/11/2022] Open
Abstract
This report serves as a guide for investigating mucormycosis infections in healthcare. We describe lessons learned from previous outbreaks and offer methods and tools that can aid in these investigations. We also offer suggestions for conducting environmental assessments, implementing infection control measures, and initiating surveillance to ensure that interventions were effective. While not all investigations of mucormycosis infections will identify a single source, all can potentially lead to improvements in infection control.
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13
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Walsh TJ, Hospenthal DR, Petraitis V, Kontoyiannis DP. Necrotizing Mucormycosis of Wounds Following Combat Injuries, Natural Disasters, Burns, and Other Trauma. J Fungi (Basel) 2019; 5:jof5030057. [PMID: 31277364 PMCID: PMC6787580 DOI: 10.3390/jof5030057] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 06/28/2019] [Accepted: 07/01/2019] [Indexed: 01/30/2023] Open
Abstract
Necrotizing mucormycosis is a devastating complication of wounds incurred in the setting of military (combat) injuries, natural disasters, burns, or other civilian trauma. Apophysomyces species, Saksenaea species and Lichtheimia (formerly Absidia) species, although uncommon as causes of sinopulmonary mucormycosis, are relatively frequent agents of trauma-related mucormycosis. The pathogenesis of these infections likely involves a complex interaction among organism, impaired innate host defenses, and biofilms related to traumatically implanted foreign materials. Effective management depends upon timely diagnosis, thorough surgical debridement, and early initiation of antifungal therapy.
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Affiliation(s)
- Thomas J Walsh
- Departments of Medicine, Pediatrics, and Microbiology & Immunology; Weill Cornell Medicine of Cornell University and New York Presbyterian Hospital, New York, NY 10065, USA.
| | - Duane R Hospenthal
- Division of Infectious Diseases, Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
| | - Vidmantas Petraitis
- Departments of Medicine, Weill Cornell Medicine of Cornell University, New York, NY 10065, USA
| | - Dimitrios P Kontoyiannis
- Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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Devauchelle P, Jeanne M, Fréalle E. Mucormycosis in Burn Patients. J Fungi (Basel) 2019; 5:jof5010025. [PMID: 30901836 PMCID: PMC6463177 DOI: 10.3390/jof5010025] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 03/19/2019] [Accepted: 03/20/2019] [Indexed: 12/27/2022] Open
Abstract
Patients with extensive burns are an important group at risk for cutaneous mucormycosis. This study aimed to perform a systematic review of all reported mucormycosis cases in burn patients from 1990 onward. A Medline search yielded identification of 7 case series, 3 outbreaks, and 25 individual cases reports. The prevalence reached 0.04%–0.6%. The median age was 42–48 in the case series and outbreaks, except for the studies from military centers (23.5–32.5) and in individual reports (29.5). The median total body surface area reached 42.5%–65%. Various skin lesions were described, none being pathognomonic: the diagnosis was mainly reached because of extensive necrotic lesions sometimes associated with sepsis. Most patients were treated with systemic amphotericin B or liposomal amphotericin B, and all underwent debridement and/or amputation. Mortality reached 33%–100% in the case series, 29%–62% during outbreaks, and 40% in individual cases. Most patients were diagnosed using histopathology and/or culture. Mucorales qPCR showed detection of circulating DNA 2–24 days before the standard diagnosis. Species included the main clinically relevant mucorales (i.e., Mucor, Rhizopus, Absidia/Lichtheimia, Rhizomucor) but also more uncommon mucorales such as Saksenaea or Apophysomyces. Contact with soil was reported in most individual cases. Bandages were identified as the source of contamination in two nosocomial outbreaks.
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Affiliation(s)
| | - Mathieu Jeanne
- CHU Lille, Centre des Brûlés, F-59000 Lille, France.
- Univ. Lille, Inserm, CHU Lille, CIC 1403-Centre d'Investigation Clinique, F-59000 Lille, France.
| | - Emilie Fréalle
- CHU Lille, Laboratoire de Parasitologie-Mycologie, F-59000 Lille, France.
- Univ. Lille, CNRS, Inserm, CHU Lille, Institut Pasteur de Lille, U1019⁻UMR8204-CIIL-Center for Infection and Immunity of Lille, F-59000 Lille, France.
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Global Epidemiology of Mucormycosis. J Fungi (Basel) 2019; 5:jof5010026. [PMID: 30901907 PMCID: PMC6462913 DOI: 10.3390/jof5010026] [Citation(s) in RCA: 409] [Impact Index Per Article: 81.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 03/14/2019] [Accepted: 03/16/2019] [Indexed: 12/16/2022] Open
Abstract
Mucormycosis is an angio-invasive fungal infection, associated with high morbidity and mortality. A change in the epidemiology of mucormycosis has been observed in recent years with the rise in incidence, new causative agents and susceptible population. The rise has been perceived globally, but it is very high in the Asian continent. Though diabetes mellitus overshadow all other risk factors in Asia, post-tuberculosis and chronic renal failure have emerged as new risk groups. The rhino-cerebral form of mucormycosis is most commonly seen in patients with diabetes mellitus, whereas, pulmonary mucormycosis in patients with haematological malignancy and transplant recipients. In immunocompetent hosts, cutaneous mucormycosis is commonly seen following trauma. The intriguing clinical entity, isolated renal mucormycosis in immunocompetent patients is only reported from China and India. A new clinical entity, indolent mucormycosis in nasal sinuses, is recently recognized. The causative agents of mucormycosis vary across different geographic locations. Though Rhizopusarrhizus is the most common agent isolated worldwide, Apophysomycesvariabilis is predominant in Asia and Lichtheimia species in Europe. The new causative agents, Rhizopus homothallicus, Mucor irregularis, and Thamnostylum lucknowense are reported from Asia. In conclusion, with the change in epidemiology of mucormycosis country-wise studies are warranted to estimate disease burden in different risk groups, analyse the clinical disease pattern and identify the new etiological agents.
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Thielen BK, Barnes AMT, Sabin AP, Huebner B, Nelson S, Wesenberg E, Hansen GT. Widespread Lichtheimia Infection in a Patient with Extensive Burns: Opportunities for Novel Antifungal Agents. Mycopathologia 2018; 184:121-128. [PMID: 29967971 DOI: 10.1007/s11046-018-0281-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 06/21/2018] [Indexed: 03/04/2023]
Abstract
The Mucorales fungi-formerly classified as the zygomycetes-are environmentally ubiquitous fungi, but generally rare causes of clinical infections. In the immunocompromised host, however, they can cause invasive, rapidly spreading infections that confer a high risk of morbidity and mortality, often despite surgical and antifungal therapy. Patients with extensive burn injuries are particularly susceptible to skin and soft-tissue infections with these organisms. Here, we present a case of Lichtheimia infection in a patient with extensive full-thickness burns that required significant and repeated surgical debridement successfully treated with isavuconazole and adjunctive topical amphotericin B washes. We also review the available literature on contemporary antifungal treatment for Lichtheimia species and related Mucorales fungi.
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Affiliation(s)
- Beth K Thielen
- Department of Medicine (Division of Infectious Diseases and International Medicine), University of Minnesota School of Medicine, Minneapolis, MN, 55455, USA. .,Department of Pediatrics (Division of Pediatric Infectious Diseases and Immunology), University of Minnesota School of Medicine, Minneapolis, MN, 55455, USA.
| | - Aaron M T Barnes
- Department of Laboratory Medicine and Pathology, University of Minnesota School of Medicine, Minneapolis, MN, 55455, USA.,Department of Microbiology & Immunology, University of Minnesota School of Medicine, Minneapolis, MN, 55455, USA
| | - Arick P Sabin
- Department of Medicine (Division of Infectious Diseases and International Medicine), University of Minnesota School of Medicine, Minneapolis, MN, 55455, USA
| | - Becky Huebner
- Department of Pathology & Laboratory Medicine, Hennepin County Medical Center, Minneapolis, MN, 55415, USA
| | - Susan Nelson
- Department of Pathology & Laboratory Medicine, Hennepin County Medical Center, Minneapolis, MN, 55415, USA
| | - Elizabeth Wesenberg
- Department of Pathology & Laboratory Medicine, Hennepin County Medical Center, Minneapolis, MN, 55415, USA
| | - Glen T Hansen
- Department of Medicine (Division of Infectious Diseases and International Medicine), University of Minnesota School of Medicine, Minneapolis, MN, 55455, USA.,Department of Laboratory Medicine and Pathology, University of Minnesota School of Medicine, Minneapolis, MN, 55455, USA.,Department of Pathology & Laboratory Medicine, Hennepin County Medical Center, Minneapolis, MN, 55415, USA
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Outbreak of Invasive Wound Mucormycosis in a Burn Unit Due to Multiple Strains of Mucor circinelloides f. circinelloides Resolved by Whole-Genome Sequencing. mBio 2018; 9:mBio.00573-18. [PMID: 29691339 PMCID: PMC5915733 DOI: 10.1128/mbio.00573-18] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Mucorales are ubiquitous environmental molds responsible for mucormycosis in diabetic, immunocompromised, and severely burned patients. Small outbreaks of invasive wound mucormycosis (IWM) have already been reported in burn units without extensive microbiological investigations. We faced an outbreak of IWM in our center and investigated the clinical isolates with whole-genome sequencing (WGS) analysis. We analyzed M. circinelloides isolates from patients in our burn unit (BU1, Hôpital Saint-Louis, Paris, France) together with nonoutbreak isolates from Burn Unit 2 (BU2, Paris area) and from France over a 2-year period (2013 to 2015). A total of 21 isolates, including 14 isolates from six BU1 patients, were analyzed by whole-genome sequencing (WGS). Phylogenetic classification based on de novo assembly and assembly free approaches showed that the clinical isolates clustered in four highly divergent clades. Clade 1 contained at least one of the strains from the six epidemiologically linked BU1 patients. The clinical isolates were specific to each patient. Two patients were infected with more than two strains from different clades, suggesting that an environmental reservoir of clonally unrelated isolates was the source of contamination. Only two patients from BU1 shared one strain, which could correspond to direct transmission or contamination with the same environmental source. In conclusion, WGS of several isolates per patients coupled with precise epidemiological data revealed a complex situation combining potential cross-transmission between patients and multiple contaminations with a heterogeneous pool of strains from a cryptic environmental reservoir. Invasive wound mucormycosis (IWM) is a severe infection due to environmental molds belonging to the order Mucorales. Severely burned patients are particularly at risk for IWM. Here, we used whole-genome sequencing (WGS) analysis to resolve an outbreak of IWM due to Mucor circinelloides that occurred in our hospital (BU1). We sequenced 21 clinical isolates, including 14 from BU1 and 7 unrelated isolates, and compared them to the reference genome (1006PhL). This analysis revealed that the outbreak was mainly due to multiple strains that seemed patient specific, suggesting that the patients were more likely infected from a pool of diverse strains from the environment rather than from direct transmission among them. This study revealed the complexity of a Mucorales outbreak in the settings of IWM in burn patients, which has been highlighted based on WGS combined with careful sampling.
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Fréalle E, Rocchi S, Bacus M, Bachelet H, Pasquesoone L, Tavernier B, Mathieu D, Millon L, Jeanne M. Real-time polymerase chain reaction detection of Lichtheimia species in bandages associated with cutaneous mucormycosis in burn patients. J Hosp Infect 2018; 99:68-74. [PMID: 29432820 DOI: 10.1016/j.jhin.2018.02.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 02/05/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Cutaneous mucormycoses, mainly due to Lichtheimia (Absidia), have occurred on several occasions in the Burn Unit of the University Hospital of Lille, France. AIM To investigate the potential vector role of non-sterile bandages used to hold in place sterile gauze used for wound dressing. METHODS Mycological analysis by conventional culture, Mucorales real-time polymerase chain reaction (qPCR), and Lichtheimia species-specific qPCR were performed on eight crepe and six elasticized bandages that were sampled on two independent occasions in March 2014 and July 2016. Characteristics of the seven Lichtheimia mucormycoses which occurred in burn patients between November 2013 and July 2016 were also collected to assess the epidemiological relationship between potentially contaminated bandages and clinical infections. FINDINGS One Lichtheimia corymbifera strain was isolated from a crepe bandage by culture, and Lichtheimia spp. qPCR was positive in six out of eight crepe and four out of six elasticized bandages. Using species-specific qPCR, Lichtheimia ramosa, Lichtheimia ornata, and L. corymbifera were identified in six out of ten, five out of ten, and four out of ten bandages, respectively. In patients with mucormycosis, L. ramosa and L. ornata were present in five and two cases, respectively. CONCLUSION Our data support the utility of Mucorales qPCR for epidemiological investigations, the potential role of these bandages in cutaneous mucormycoses in burn patients in our centre, and, consequently, the need for sterile bandages for the dressing of extensive wounds.
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Affiliation(s)
- E Fréalle
- Université de Lille, U1019 - UMR 8204 - CIIL - Center for Infection and Immunity of Lille, F-59000 Lille, France; CNRS, UMR 8204, F-59000 Lille, France; Inserm, U1019, F-59000 Lille, France; CHU Lille, Laboratoire de Parasitologie-Mycologie, F-59000 Lille, France; Institut Pasteur de Lille, F-59000 Lille, France.
| | - S Rocchi
- Chrono-Environnement UMR 6249 CNRS, Université de Bourgogne Franche-Comté & Laboratoire de Parasitologie-Mycologie, CHU de Besançon, France
| | - M Bacus
- CHU Lille, Pôle d'Anesthésie-Réanimation, Centre de Traitement des Brûlés, F-59000 Lille, France
| | - H Bachelet
- CHU Lille, Pharmacie Centrale, F-59000 Lille, France
| | - L Pasquesoone
- CHU Lille, Service de chirurgie plastique, esthétique et reconstructrice - Centre de Traitement des Brûlés, F-59000 Lille, France
| | - B Tavernier
- CHU Lille, Pôle d'Anesthésie-Réanimation, Centre de Traitement des Brûlés, F-59000 Lille, France
| | - D Mathieu
- CHU Lille, Pôle de Réanimation, F-59000 Lille, France
| | - L Millon
- Chrono-Environnement UMR 6249 CNRS, Université de Bourgogne Franche-Comté & Laboratoire de Parasitologie-Mycologie, CHU de Besançon, France
| | - M Jeanne
- CHU Lille, Pôle d'Anesthésie-Réanimation, Centre de Traitement des Brûlés, F-59000 Lille, France
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Could Histoplasma capsulatum Be Related to Healthcare-Associated Infections? BIOMED RESEARCH INTERNATIONAL 2015; 2015:982429. [PMID: 26106622 PMCID: PMC4461736 DOI: 10.1155/2015/982429] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Revised: 05/12/2015] [Accepted: 05/12/2015] [Indexed: 02/07/2023]
Abstract
Healthcare-associated infections (HAI) are described in diverse settings. The main etiologic agents of HAI are bacteria (85%) and fungi (13%). Some factors increase the risk for HAI, particularly the use of medical devices; patients with severe cuts, wounds, and burns; stays in the intensive care unit, surgery, and hospital reconstruction works. Several fungal HAI are caused by Candida spp., usually from an endogenous source; however, cross-transmission via the hands of healthcare workers or contaminated devices can occur. Although other medically important fungi, such as Blastomyces dermatitidis, Paracoccidioides brasiliensis, and Histoplasma capsulatum, have never been considered nosocomial pathogens, there are some factors that point out the pros and cons for this possibility. Among these fungi, H. capsulatum infection has been linked to different medical devices and surgery implants. The filamentous form of H. capsulatum may be present in hospital settings, as this fungus adapts to different types of climates and has great dispersion ability. Although conventional pathogen identification techniques have never identified H. capsulatum in the hospital environment, molecular biology procedures could be useful in this setting. More research on H. capsulatum as a HAI etiologic agent is needed, since it causes a severe and often fatal disease in immunocompromised patients.
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Abstract
BACKGROUND Mucormycosis is an invasive fungal infection with a high fatality rate. We investigated an outbreak of mucormycosis in a pediatric hospital to determine routes of pathogen transmission from the environment and prevent additional infections. METHODS A case was defined as a hospital-onset illness consistent with mucormycosis, confirmed by culture or histopathology. Case-patient medical records were reviewed for clinical course and exposure to items and locations within the hospital. Environmental samples were collected from air and surfaces. Fungal isolates collected from case-patients and the environmental samples were identified using DNA sequencing. RESULTS Five case-patients had hospital-associated cutaneous mucormycosis over an 11-month period; all subsequently died. Three case-patients had conditions known to be associated with susceptibility to mucormycosis, while 2 had cardiac conditions with persistent acidosis. The cases occurred on several different wards throughout the hospital, and hospital linens were the only exposure identified as common to the case-patients. Rhizopus species were recovered from 26 (42%) of 62 environmental samples from clean linens and associated areas and from 1 (4%) of 25 samples from nonlinen-related items. Case-patients were infected with Rhizopus delemar, which was also isolated from cultures of clean linens and clean linen delivery bins from the off-site laundry facility. CONCLUSIONS Hospital linens were identified as a vehicle that carried R. delemar into contact with susceptible patients. Fungal species identification using DNA-based methods is useful for corroborating epidemiologic links in hospital outbreak investigations. Hospital linens should be laundered, packaged, shipped and stored in a manner that minimizes exposure to environmental contaminants.
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Bandettini R, Tuo P, Tamisani AM, Di Marco E, Mantero E. Severe Cutaneous Zygomycosis: Evaluation of Treatment with High Doses of Liposomal Amphotericin B in a One-Year Old Child. J Chemother 2013; 19:347-9. [PMID: 17594934 DOI: 10.1179/joc.2007.19.3.347] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Neblett Fanfair R, Benedict K, Bos J, Bennett SD, Lo YC, Adebanjo T, Etienne K, Deak E, Derado G, Shieh WJ, Drew C, Zaki S, Sugerman D, Gade L, Thompson EH, Sutton DA, Engelthaler DM, Schupp JM, Brandt ME, Harris JR, Lockhart SR, Turabelidze G, Park BJ. Necrotizing cutaneous mucormycosis after a tornado in Joplin, Missouri, in 2011. N Engl J Med 2012; 367:2214-25. [PMID: 23215557 DOI: 10.1056/nejmoa1204781] [Citation(s) in RCA: 254] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Mucormycosis is a fungal infection caused by environmentally acquired molds. We investigated a cluster of cases of cutaneous mucormycosis among persons injured during the May 22, 2011, tornado in Joplin, Missouri. METHODS We defined a case as a soft-tissue infection in a person injured during the tornado, with evidence of a mucormycete on culture or immunohistochemical testing plus DNA sequencing. We conducted a case-control study by reviewing medical records and conducting interviews with case patients and hospitalized controls. DNA sequencing and whole-genome sequencing were performed on clinical specimens to identify species and assess strain-level differences, respectively. RESULTS A total of 13 case patients were identified, 5 of whom (38%) died. The patients had a median of 5 wounds (range, 1 to 7); 11 patients (85%) had at least one fracture, 9 (69%) had blunt trauma, and 5 (38%) had penetrating trauma. All case patients had been located in the zone that sustained the most severe damage during the tornado. On multivariate analysis, infection was associated with penetrating trauma (adjusted odds ratio for case patients vs. controls, 8.8; 95% confidence interval [CI], 1.1 to 69.2) and an increased number of wounds (adjusted odds ratio, 2.0 for each additional wound; 95% CI, 1.2 to 3.2). Sequencing of the D1-D2 region of the 28S ribosomal DNA yielded Apophysomyces trapeziformis in all 13 case patients. Whole-genome sequencing showed that the apophysomyces isolates were four separate strains. CONCLUSIONS We report a cluster of cases of cutaneous mucormycosis among Joplin tornado survivors that were associated with substantial morbidity and mortality. Increased awareness of fungi as a cause of necrotizing soft-tissue infections after a natural disaster is warranted.
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Affiliation(s)
- Robyn Neblett Fanfair
- Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, USA
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Repetto EC, Giacomazzi CG, Castelli F. Hospital-related outbreaks due to rare fungal pathogens: a review of the literature from 1990 to June 2011. Eur J Clin Microbiol Infect Dis 2012; 31:2897-904. [PMID: 22661170 DOI: 10.1007/s10096-012-1661-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2012] [Accepted: 05/15/2012] [Indexed: 11/28/2022]
Abstract
Fungi can cause severe infections. Two or more nosocomial unusual fungal infections diagnosed in a short period should be assumed as an outbreak. The review's aim was to collect data to improve their management. The free online worldwide database for nosocomial outbreaks ( http://www.outbreak-database.com ) and the PubMed/MEDLINE database were used to collect the English literature published from 1990 to June 2011. The more common Candida spp. and Aspergillus spp. infections were excluded. For each outbreak, the following data were reviewed: species, duration, source and site of infection, ward, risk factors, number of patients infected, treatment, related mortality, type of epidemiological study and time elapsed between index cases and second cases. Thirty-six reports were considered: yeasts caused the majority of the outbreaks (16 out of 36). The median values for the overall duration, number of infected people per outbreak and infection-related mortality were 5 months, 4 and 20 %, respectively. Eighteen cases were caused by contaminated substances and 13 cases were hypothesised as human-transmitted. Nosocomial outbreaks due to rare fungal pathogens involve few patients but have high related mortality. These results could be explained by the diagnostic delay, the inability of recognising the source of the infections and the challenges of the treatment. More efforts should be concentrated to implement the application of proper hygiene practices to avoid human-human transmission.
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Affiliation(s)
- E C Repetto
- Appropriate Methodologies and Techniques in International Cooperation of Development, University of Brescia, Piazzale Spedali Civili 1, 25123, Brescia, Italy.
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Rammaert B, Lanternier F, Zahar JR, Dannaoui E, Bougnoux ME, Lecuit M, Lortholary O. Healthcare-associated mucormycosis. Clin Infect Dis 2012; 54 Suppl 1:S44-54. [PMID: 22247444 DOI: 10.1093/cid/cir867] [Citation(s) in RCA: 183] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Mucormycosis is a severe emerging invasive fungal infection that occurs as a consequence of environmental exposure. We exhaustively reviewed all the cases of mucormycosis (European Organisation for Research and Treatment of Cancer/Mycoses Study Group 2008 criteria) attributed to healthcare procedures that occurred between 1970 and 2008. A total of 169 cases were studied (29% children, 61% male). Major underlying diseases were solid organ transplantation (24%), diabetes mellitus (22%), and severe prematurity (21%). Skin was the most common localization (57%), followed by gastrointestinal tract (15%). Culture results were available in 75% (92% positive), and results of histological examination were positive in 95%. Rhizopus was the most frequent genus (43%). Infection portal of entry included surgery and presence of medical devices such as catheters or adhesive tape. Outbreaks and clusters were related to adhesive bandages (19 cases), wooden tongue depressors (n = 5), ostomy bags (n = 2), water circuitry damage (n = 2), and adjacent building construction (n = 5). Thorough investigations are mandatory to identify healthcare-associated mucormycosis, notably in neonatology, hematological, and transplantation units.
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Affiliation(s)
- Blandine Rammaert
- Sorbonne Paris Cité, Service des Maladies Infectieuses et Tropicales, Hôpital Necker-Enfants Malades, APHP, Université Paris-Descartes, Centre d'Infectiologie Necker-Pasteur, 149 rue de Sèvres, Paris Cedex 15, France
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A cluster of mucormycosis infections in hematology patients: challenges in investigation and control of invasive mold infections in high-risk patient populations. Diagn Microbiol Infect Dis 2011; 71:72-80. [DOI: 10.1016/j.diagmicrobio.2010.12.022] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2010] [Revised: 12/08/2010] [Accepted: 12/20/2010] [Indexed: 11/19/2022]
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Shakoor S, Jabeen K, Idrees R, Jamil B, Irfan S, Zafar A. Necrotising fasciitis due to Absidia corymbifera in wounds dressed with non sterile bandages. Int Wound J 2011; 8:651-5. [PMID: 21883933 DOI: 10.1111/j.1742-481x.2011.00839.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
We present three cases of Absidia corymbifera necrotising fasciitis presenting to our centre within 1 month of each other. All patients had wound dressings with non sterile crepe bandages at peripheral centres. One patient was lost to follow-up, another improved on timely antifungal therapy, while the last patient succumbed to disseminated infection. We propose that traumatic and deep wounds be dressed with sterile roller bandages to prevent outbreaks of wound zygomycosis.
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Affiliation(s)
- Sadia Shakoor
- Department of Pathology and Medicine, Aga Khan University Hospital, Karachi, Pakistan
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Mignogna MD, Fortuna G, Leuci S, Adamo D, Ruoppo E, Siano M, Mariani U. Mucormycosis in immunocompetent patients: a case-series of patients with maxillary sinus involvement and a critical review of the literature. Int J Infect Dis 2011; 15:e533-40. [DOI: 10.1016/j.ijid.2011.02.005] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2010] [Revised: 08/29/2010] [Accepted: 02/24/2011] [Indexed: 12/14/2022] Open
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Alangaden GJ. Nosocomial fungal infections: epidemiology, infection control, and prevention. Infect Dis Clin North Am 2011; 25:201-25. [PMID: 21316001 DOI: 10.1016/j.idc.2010.11.003] [Citation(s) in RCA: 104] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Fungal infections are an increasing cause of morbidity and mortality in hospitalized patients. This article reviews the current epidemiology of nosocomial fungal infections in adult patients, with an emphasis on invasive candidiasis and aspergillosis. Recently published recommendations and guidelines for the control and prevention of these nosocomial fungal infections are summarized.
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Affiliation(s)
- George J Alangaden
- Division of Infectious Diseases, Wayne State University, 3990 John R, Suite 5930, Detroit, MI 48201, USA.
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Hayette MP, Christiaens G, Mutsers J, Barbier C, Huynen P, Melin P, de Mol P. Filamentous fungi recovered from the water distribution system of a Belgian university hospital. Med Mycol 2010; 48:969-74. [DOI: 10.3109/13693781003639601] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Successful triple combination therapy of disseminated absidia corymbifera infection in an adolescent with osteosarcoma. J Pediatr Hematol Oncol 2010; 32:131-3. [PMID: 20098334 DOI: 10.1097/mph.0b013e3181ca0dcf] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Mucormycosis are opportunistic infections mostly observed in immunocompromised patients. We report the case of a 13-year-old girl who suffered a systemic mucormycosis without presenting the usual risk factors. She was undergoing antineoplastic chemotherapy for advanced osteosarcoma of the femur with an uncommunicative pathologic fracture and pulmonary metastasis. Absidia corymbifera was isolated from skin lesions at the primary tumor site. She subsequently developed fungal pulmonary localizations and blood vessel thrombosis. Surgical treatment together with systemic, high doses of liposomal amphotericin B, posaconazole, and caspofungin cured the local infection and controlled systemic lesions. Unfortunately, the break in chemotherapy led to pulmonary metastasis progression.
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Abstract
Invasive fungal infections are major causes of morbidity and mortality in critically ill patients. Foremost among these is invasive candidiasis. In recent years, invasive aspergillosis (IA) and zygomycosis have emerged as major problems in susceptible, critically ill patients. Risk factors for invasive fungal infections, including disrupted anatomic barriers, suppressed antifungal host responses, and exposure to potentially opportunistic fungi are common in critically ill patients. The expanded antifungal armamentarium and advent of rapid diagnostic techniques are altering the approach to invasive fungal infections in the intensive care unit (ICU). Herein, we review recent developments in the field of antifungal host defenses, the changing epidemiology of fungal infections in the ICU, the pharmacology of antifungal agents of importance to critically ill patients, and the evolving approaches to therapy in this setting.
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Affiliation(s)
- Shmuel Shoham
- Section of Infectious Diseases, Washington Hospital Center, Washington, D.C., MedStar Research Institute, Washington, DC 20010, USA.
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Corti G, Mondanelli N, Losco M, Bartolini L, Fontanelli A, Paradisi F. Post-traumatic infection of the lower limb caused by rare Enterobacteriaceae and Mucorales in a young healthy male. Int J Infect Dis 2009; 13:e57-60. [DOI: 10.1016/j.ijid.2008.06.029] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2008] [Revised: 05/05/2008] [Accepted: 06/17/2008] [Indexed: 11/30/2022] Open
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Almaslamani M, Taj-Aldeen SJ, Garcia-Hermoso D, Dannaoui E, Alsoub H, Alkhal A. An increasing trend of cutaneous zygomycosis caused byMycocladus corymbifer(formerlyAbsidia corymbifera): report of two cases and review of primary cutaneousMycocladusinfections. Med Mycol 2009; 47:532-8. [DOI: 10.1080/13693780802595746] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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Liu ZH, Lv GX, Chen J, Sang H, She XD, Chen XJ, Sun JF, Shen YN, Zeng XS, Liu WD. Primary cutaneous zygomycosis due toAbsidia corymbiferain a patient with cutaneous T cell lymphoma. Med Mycol 2009; 47:663-8. [DOI: 10.1080/13693780902806647] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
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Absidia corymbifera Fungal Infection in Burns: A Case Report and Review of the Literature. J Burn Care Res 2008; 29:416-9. [DOI: 10.1097/bcr.0b013e318166da78] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Septic Arthritis due to Absidia corymbifera in a Patient with HIV-1 Infection. Infection 2007; 36:279-81. [DOI: 10.1007/s15010-007-6297-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2006] [Accepted: 03/27/2007] [Indexed: 10/22/2022]
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Tiong WHC, Ismael T, McCann J. Post-traumatic and post-surgical Absidia corymbifera infection in a young, healthy man. J Plast Reconstr Aesthet Surg 2006; 59:1367-71. [PMID: 17113521 DOI: 10.1016/j.bjps.2006.03.053] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2005] [Accepted: 03/09/2006] [Indexed: 11/19/2022]
Abstract
Absidia corymbifera infection in a healthy individual is rare. Most of the infection occurs in immunocompromised patients or diabetic patients. Cutaneous and subcutaneous mucormycosis have been increasingly reported in the literature as a result of massive trauma with contaminated wounds. We present a case of cutaneous mucormycosis in a healthy, young patient after surgical amputation for a crush injury of the leg. We also highlight the importance of the high index of clinical suspicion in the diagnosis and treatment of this fungal infection in the hype of methicillin-resistant Staphylococcus aureus (MRSA) infection in hospital setting these days. Despite an initial life-saving amputation, it was inadequate to ensure the eradication of A. corymbifera infection. A second amputation was required with parenteral liposomal amphotericin B to achieve a satisfactory cure.
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Affiliation(s)
- William H C Tiong
- Department of Plastic, Reconstructive and Hand Surgery, University College Hospital Galway, Ireland.
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