Preventing invasive fungal infection during hospital building works

Non-touch treatment to solve the persistent contamination of culture plates with Aspergillus niger in a clinical microbiology laboratory of Spain

A pseudo-outbreak of Aspergillus caused by false positive cultures can have a high sanitary impact. We determined the effectiveness (fungal load elimination) of a non-touch disinfection system, vs conventional disinfection methods, to solve steady contamination of culture plates with Aspergillus niger at a clinical microbiology laboratory. Routine cleaning-disinfection (RCD), intensive cleaning-disinfection (ICD), and terminal airborne disinfection (TAD) were employed in stages. Air sampling was carried out before and after each procedure. The effectiveness of TAD on contact surfaces was tested by surface sampling. After RCD, ICD, and TAD, there was a mean decrease of 5.4 (95% CI = 1.8-9.0), 19.2 (95% CI = 12.4-26.0), and 4.4 (95% CI = 2.5-6.3) CFU per tested area, and 46.2%, 21.7%, and 95.5% of contaminated areas became sterile, respectively. There was a mean decrease of 30.6 CFU per tested surface (p < 0.0007) and 50% of tested surfaces became sterile. Global effectiveness of RCD, ICD, and TAD was 68.8% (95% CI = 68.5-69.1), 82.2% (95% CI = 82.1-82.3), and 99.0% (95% CI = 98.8-99.2), respectively. The effectiveness was higher with TAD (4.1 CFU/cm2 less than with ICD; p = 0.0290). No further contamination has occurred since then. When construction and renovation activities are discarded and RCD and ICD practices are insufficient, non-touch disinfection remove residual dust contamination and avoid recurrence.

A pseudo-outbreak of COVID-19 associated pulmonary aspergillosis: a microbiological investigation of both the patients and the environment

Background

We experienced a pseudo-outbreak of aspergillosis in a newly constructed COVID-19 ward. Within the first 3 months from the commencement of the ward, six intubated patients of COVID-19 developed probable or possible pulmonary aspergillosis. We suspected an outbreak of pulmonary aspergillosis associated with ward construction and launched air sampling for the investigation of the relationship between these.

Methods

The samples were collected at 13 locations in the prefabricated ward and three in the general wards, not under construction, as a control.

Results

The results from samples revealed different species of Aspergillus from those detected by the patients. Aspergillus sp. was detected not only from the air samples in the prefabricated ward but also in the general ward.

Discussion

In this investigation, we could not find evidence of the outbreak that links the construction of the prefabricated ward with the occurrence of pulmonary aspergillosis. It might suggest that this series of aspergillosis was more likely occurred from fungi that inherently colonized patients, and was associated with patient factors such as severe COVID-19 rather than environmental factors. Once an outbreak originating from building construction is suspected, it is important to conduct an environmental investigation including an air sampling.

A Clustered Case Series of Mucorales Detection in Respiratory Samples from COVID-19 Patients in Intensive Care, France, August to September 2021

While COVID-19-associated pulmonary aspergillosis is now well described in developed countries, COVID-19-associated mucormycosis (CAM) has seemed to remain quite rare in Europe. A retrospective study was performed between March 2020 to September 2021 among COVID-19 adult patients in the intensive care unit (ICU) at Toulouse Hospital (Southern France). PCR screening on respiratory samples, which target Aspergillus or Mucorales DNA, were performed, and the number of fungal detections was evaluated monthly during the study period. During the 19 months of the study, 44 (20.3%) COVID-19 ICU patients had a positive PCR for Aspergillus, an overall rate in keeping with the incidence of ICU COVID-19 patients. Ten patients (7.1%) had a positive Mucorales PCR over the same period. Surprisingly, 9/10 had a positive Mucor/Rhizopus PCR in August-September 2021, during the fourth Delta SARS-CoV-2 variant wave. Epidemic investigations have identified a probable environmental cause linked to construction works in the vicinity of the ICU (high levels of airborne spores due to the mistaken interruption of preventive humidification and summer temperature). Even if CAM are apparently rare in Europe, a cluster can also develop in industrialised countries when environmental conditions (especially during construction work) are associated with a high number of COVID-19 patients in the ICU.

Introduction to the updated Australasian consensus guidelines for the management of invasive fungal disease and use of antifungal agents in the haematology/oncology setting, 2021

This article introduces the fourth update of the Australian and New Zealand consensus guidelines for the management of invasive fungal disease and use of antifungal agents in the haematology/oncology setting. These guidelines are comprised of nine articles as presented in this special issue of the Internal Medicine Journal. This introductory chapter outlines the rationale for the current update and the steps taken to ensure implementability in local settings. Given that 7 years have passed since the previous iteration of these guidelines, pertinent contextual changes that impacted guideline content and recommendations are discussed, including the evolution of invasive fungal disease (IFD) definitions. We also outline our approach to guideline development, evidence grading, review and feedback. Highlights of the 2021 update are presented, including expanded scope to provide more detailed coverage of common and emerging fungi such as Aspergillus and Candida species, and emerging fungi, and a greater focus on the principles of antifungal stewardship. We also introduce an entirely new chapter dedicated to helping healthcare workers convey important concepts related to IFD, infection prevention and antifungal therapy, to patients.

Differences in clinical characteristics of invasive tracheobronchial aspergillosis according to the presence of invasive pulmonary aspergillosis

Background

The association of invasive tracheobronchial aspergillosis (ITBA) with invasive pulmonary aspergillosis (IPA) is not well established. We aimed to compare clinical characteristics between patients who exhibited ITBA with IPA and those who exhibited isolated ITBA (iITBA). Additionally, the usefulness of serum or bronchial galactomannan (GM) tests in diagnosing ITBA was evaluated.

Methods

This retrospective single-center case-control study was conducted over a period of 4 years. Fifteen patients were enrolled after confirming the presence of ITBA using bronchoscopy-guided biopsy (iITBA, 7 vs. ITBA+IPA, 8). Clinical characteristics of patients and results obtained from serum or bronchial GM tests were compared between the two groups. Mortality was assessed using data collected from a 6-month follow-up period.

Results

The ITBA+IPA group showed a higher prevalence of hematologic malignancy (75% vs. 14%, p=0.029), a greater number of patients with multiple bronchial ulcers (75% vs. 14%, p=0.029), lower platelet counts (63,000/μL vs. 229,000/μL, p<0.001), and a mortality rate which was significantly higher (63% vs. 0%, p=0.026) than the iITBA group. In the ITBA+IPA group, 57% of patients tested positive according to the serum GM assay, whereas in the iITBA group, all patients tested negative (p=0.070). The bronchial GM level was high in both groups, but there was no significant difference between them.

Conclusion

Patients with ITBA+IPA had a greater number of hematologic malignancies with lower platelet counts and a poorer prognosis than patients diagnosed with iITBA. Findings obtained from bronchoscopy and bronchial GM tests were more useful in diagnosing ITBA than the serum GM test results.

A Guide to Investigating Suspected Outbreaks of Mucormycosis in Healthcare

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.

Measuring airflow through the portable high-efficiency air filtration (PHEAF) device to assess reliability of instrument and sample location

The portable high-efficiency air filtration (PHEAF) device is an engineering control common to the environmental remediation industry. Damage to the high-efficiency particulate air (HEPA) filter (e.g., filtration media, gasket), improper installation of the filter into the mounting frame, or defects in the filtration housing affect the capture efficiency of the device. PHEAF devices operating at less than marketed efficiencies justify periodic leak testing of the PHEAF device, especially when the filtered air is exhausted into occupied spaces. A leak test is accomplished by injecting a known concentration of aerosol upstream of the HEPA filter and measuring the percentage of aerosol penetrating through the filtration system. The test protocol scripted for stationary systems (i.e., biological safety cabinets) states that upstream concentrations can be empirically determined using the aerosol photometer to measure particulate matter (PM) in the airstream. This practice requires a homogenous mixture of the aerosol challenge agent within the airstream. However, design of the PHEAF device does not include a validated induction point for the aerosol. Absent of an acceptable means to achieve a homogenous mixture for upstream measurement, the aerosol concentration is mathematically derived based on the measured air volume passing through the PHEAF equipment. In this study, intake volume and exhaust volume for each PHEAF device were measured by either the balometer or the hot wire anemometer. Variability of measurements was examined by instrument and sample location (intake vs. exhaust) to understand which combination would be most consistent for measuring airflow volume. From this study, the authors conclude that the balometer is preferred compared with the hot wire anemometer for measuring airflow through the PHEAF device. Exhaust measurement by balometer seems more reliable than intake measurements by hot wire anemometer. Implications: Although testing of PHEAF devices is recommended by various public health authorities, no nationally recognized test protocol has been published in the United States. In support of measuring the performance of the PHEAF device in a field setting, this study evaluated the hot wire anemometer and balometer techniques and sample locations (intake vs. exhaust) to reliably measure airflow through the PHEAF device. Since accuracy of the particle measurement is associated with airflow volume, it is essential to obtain a true airflow reading. This study suggests that the balometer was more consistent in measuring airflow through the PHEAF device.

Cost-effectiveness analysis of interventions for prevention of invasive aspergillosis among leukemia patients during hospital construction activities

OBJECTIVES

Invasive Aspergillosis (IA) is a serious problem among hematological patients and it is associated with high mortality. This situation can worsen at times of hospital construction, however there are several preventive measures available. This work aims to define the cost-effectiveness of some of these interventions.

PATIENTS AND METHODS

A decision tree model was used, it was divided into four arms according to each 1 of the interventions performed. A cost-effectiveness incremental analysis comparing environmental control measures, high efficiency particulate absorption (HEPA) filter installation and prophylaxis with posaconazole was done. Probabilistic and deterministic sensitivity analyses were also carried out.

RESULTS

Among 86 patients with 175 hospitalization episodes, the incidence of IA with environmental protection measures, antifungal prophylaxis and hospitalization in rooms with HEPA filters was 14.4%, 6.3% and 0%, respectively. An Incremental Cost Effectiveness Ratio analysis was performed and it was found that HEPA filtered rooms and environmental protection measures are cost saving interventions when compared with posaconazole prophylaxis (-$2665 vs -$4073 vs $42 531 US dollars, respectively) for IA episode prevented.

CONCLUSION

The isolation of inpatients with acute leukemia during hospital construction periods in HEPA filtered rooms could reduce the incidence of IA and might be a cost-effective prevention strategy.

Evaluation of hirst-type spore trap to monitor environmental fungal load in hospital

The main purpose was to validate the use of outdoor-indoor volumetric impaction sampler with Hirst-type spore traps (HTSTs) to continuously monitor fungal load in order to prevent invasive fungal infections during major structural work in hospital settings. For 4 weeks, outdoor fungal loads were quantified continuously by 3 HTSTs. Indoor air was sampled by both HTST and viable impaction sampler. Results were expressed as particles/m³ (HTST) or colony-forming units (CFU)/m³ (biocollector). Paired comparisons by day were made with Wilcoxon’s paired signed-rank test or paired Student’s t-test as appropriate. Paired airborne spore levels were correlated 2 by 2, after log-transformation with Pearson’s cross-correlation. Concordance was calculated with kappa coefficient (κ). Median total fungal loads (TFLs) sampled by the 3 outdoor HTSTs were 3,025.0, 3,287.5 and 3,625.0 particles/m³ (P = 0.6, 0.6 and 0.3).—Concordance between Aspergillaceae fungal loads (AFLs, including Aspergillus spp. + Penicillium spp.) was low (κ = 0.2). A low positive correlation was found between TFLs sampled with outdoor HTST and indoor HTST with applying a 4-hour time lag, r = 0.30, 95% CI (0.23–0.43), P<0.001. In indoor air, Aspergillus spp. were detected by the viable impaction sampler on 63.1% of the samples, whereas AFLs were found by HTST-I on only 3.6% of the samples. Concordance between Aspergillus spp. loads and AFLs sampled with the 2 methods was very low (κ = 0.1). This study showed a 4-hour time lag between increase of outdoor and indoor TFLs, possibly due to insulation and aeraulic flow of the building. Outdoor HTSTs may permit to quickly identify (after 48 hours) time periods with high outdoor fungal loads. An identified drawback is that a too low sample area read did not seem to enable detection of Aspergillaceae spores efficiently. Indoor HTSTs may not be recommended at this time, and outdoor HTSTs need further study. Air sampling by viable impaction sampler remains the reference tool for quantifying fungal contamination of indoor air in hospitals.

High diversity of airborne fungi in the hospital environment as revealed by meta-sequencing-based microbiome analysis

Invasive fungal infections acquired in the hospital have progressively emerged as an important cause of life-threatening infection. In particular, airborne fungi in hospitals are considered critical pathogens of hospital-associated infections. To identify the causative airborne microorganisms, high-volume air samplers were utilized for collection, and species identification was performed using a culture-based method and DNA sequencing analysis with the Illumina MiSeq and HiSeq 2000 sequencing systems. Few bacteria were grown after cultivation in blood agar. However, using microbiome sequencing, the relative abundance of fungi, Archaea species, bacteria and viruses was determined. The distribution characteristics of fungi were investigated using heat map analysis of four departments, including the Respiratory Intensive Care Unit, Intensive Care Unit, Emergency Room and Outpatient Department. The prevalence of Aspergillus among fungi was the highest at the species level, approximately 17% to 61%, and the prevalence of Aspergillus fumigatus among Aspergillus species was from 34% to 50% in the four departments. Draft genomes of microorganisms isolated from the hospital environment were obtained by sequence analysis, indicating that investigation into the diversity of airborne fungi may provide reliable results for hospital infection control and surveillance.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Introduction to the updated Australian and New Zealand consensus guidelines for the use of antifungal agents in the haematology/oncology setting, 2014

This article introduces the second revision of the Australian and New Zealand consensus guidelines for the use of antifungal agents in the haematology/oncology setting. The current update occurs within the context of a growing population at risk of invasive fungal disease, improved understanding of risk factors, availability of new diagnostic tests, a much-expanded evidence base and changing clinical paradigms. Here, we provide an overview of the history and purpose of the guidelines, including changes in scope since the last clinical update was published in 2008. The process for development, and for enabling review of draft recommendations by end-users and other relevant stakeholders, is described. The approach to assigning levels of evidence and grades of recommendation is also provided, along with a comparison to international grading systems.

Consensus guidelines for implementation of quality processes to prevent invasive fungal disease and enhanced surveillance measures during hospital building works, 2014

Healthcare-associated fungal outbreaks impose a substantial economic burden on the health system and typically result in high patient morbidity and mortality, particularly in the immunocompromised host. As the population at risk of invasive fungal infection continues to grow due to the increased burden of cancer and related factors, the need for hospitals to employ preventative measures has become increasingly important. These guidelines outline the standard quality processes hospitals need to accommodate into everyday practice and at times of healthcare-associated outbreak, including the role of antifungal stewardship programmes and best practice environmental sampling. Specific recommendations are also provided to help guide the planning and implementation of quality processes and enhanced surveillance before, during and after high-risk activities, such as hospital building works. Areas in which information is still lacking and further research is required are also highlighted.

The ecology of pneumocystis: perspectives, personal recollections, and future research opportunities

I am honored to receive the second Lifetime Achievement Award by International Workshops on Opportunistic Protists and to give this lecture. My research involves Pneumocystis, an opportunistic pulmonary fungus that is a major cause of pneumonia ("PcP") in the immunocompromised host. I decided to focus on Pneumocystis ecology here because it has not attracted much interest. Pneumocystis infection is acquired by inhalation, and the cyst stage appears to be the infective form. Several fungal lung infections, such as coccidiomycosis, are not communicable, but occur by inhaling < 5 μm spores from environmental sources (buildings, parks), and can be affected by environmental factors. PcP risk factors include environmental constituents (temperature, humidity, SO2 , CO) and outdoor activities (camping). Clusters of PcP have occurred, but no environmental source has been found. Pneumocystis is communicable and outbreaks of PcP, especially in renal transplant patients, are an ongoing problem. Recent evidence suggests that most viable Pneumocystis organisms detected in the air are confined to a patient's room. Further efforts are needed to define the risk of Pneumocystis transmission in health care facilities; to develop more robust preventive measures; and to characterize the effects of climatological and air pollutant factors on Pneumocystis transmission in animal models similar to those used for respiratory viruses.

Sound Levels, Staff Perceptions, and Patient Outcomes During Renovation Near the Neonatal Intensive Care Unit

Objective:

Sound levels, staff perceptions, and patient outcomes were evaluated during a year-long hospital renovation project on the floor above a neonatal intensive care unit (NICU).

Background:

Construction noise may be detrimental to NICU patients and healthcare professionals. There are no comprehensive studies evaluating the impact of hospital construction on sound levels, staff, and patients.

Methods:

Prospective observational study comparing sound measures and patient outcomes before, during, and after construction. Staff were surveyed about the construction noise, and hospital employee satisfaction scores are reported.

Results:

Equivalent sound levels were not significantly higher during construction. Most staff members (89%) perceived the renovation period as louder, and 83% reported interruptions of their work. Patient outcomes were the same or more positive during construction. Very low birth weight (VLBW infants were less likely to require 24+ hours' mechanical ventilation during construction: 54% vs. 59% before ( OR = 1.6, p = 0.018) and 62% after ( OR = 1.48, p = 0.065); and they required a shorter total period of mechanical ventilation: 3.6 days vs. 8.0 before ( p = 0.011) and 9.5 after ( p = 0.001). VLBW newborns' differences in ventilation days were mostly in the upper extremes; medians were similar in all periods: 0.6 days vs. 1 day preconstruction and 2 days postconstruction.

Conclusions:

Construction above the NICU did not cause substantially louder sound levels, but staff perceived important changes in noise and work routines. No evidence suggested that patients were negatively affected by the renovation period. Meticulous construction planning remains necessary to avoid interference with patient care and caregiver work environments.

Refurbishment works in a hospital during normal operation

BACKGROUND

Construction and renovation work in hospitals pose risks of fungal airborne infections for immunosuppressed patients. If possible, reconstruction work will be postponed to periods without patient treatment. However, in many situations urgent damage demands immediate refurbishment works before the transferring of patients to other wards or closure of wards is possible. Reported here are infection control related measures and implemented procedures after two incidents of water damage which occurred on a surgical ward and an intensive care unit at the University hospital of Essen.

METHODS

Between January and April 2009 and between September and October 2009, respectively, concentration of air-borne particles and number of viable fungi were measured at two surgical wards and one ICU. Preventive Infection Control Measures included erection of protective walls and HEPA filtration of air from the renovation area.

RESULTS

During the renovation work on the surgical ward concentrations of moulds and particles ≥5 µm were significantly higher on the left side of the renovation area than on the right side (p=0.036 and p<0.001). Concentrations of particles ≥1 µm and particles ≥5 µm on both sides of the renovation area were significantly increased when compared with the control ward on the same floor but not when compared with the control ward on the other floor. Particles of all size were significantly elevated on the ICU during the renovation work. Aspergillus fumigatus could neither be cultured of the air of cardiac surgery intensive care unit nor of the intermediate care unit (control ward). During renovation works there was no nosocomial mould infection of patients treated on the two wards.

CONCLUSION

Provided that the renovation area is tightly insulated from the areas of patient care on a ward, closure does not seem to be necessary during renovation works because variation of airborne fungi is similar to that of outdoor or control air. However a multidisciplinary team should be established. This team should perform risk assessment and determine necessary protective measures before starting any construction, renovation or maintenance work in health care settings.

Controlling risk in the built environment — evaluation of a risk assessment algorithm

This study describes a small-scale evaluation of an environmental risk assessment algorithm. The risk assessment algorithm was developed in response to a local need to adapt the Healthcare Associated Infection System for Controlling Risk in the Built Environment (HAI-SCRIBE) guidance (Health Facilities Scotland, 2007a) for use with routine maintenance and repair works in order to ensure measures were put in place to protect patients from environmental contamination during such work.

The suitability and acceptability of the risk assessment algorithm was evaluated by Estates and Maintenance staff using a two-stage staff questionnaire. We present the results of the evaluation and describe the advantages of implementing this model of environmental assessment. Limitations and possible further work are considered, including the use of the risk assessment algorithm to confirm its suitability within a larger study group.

Correlation between the incidence of nosocomial aspergillosis and room reconstruction of a haematological ward

Invasive pulmonary aspergillosis (IPA) represents ~ a major cause of morbidity and mortality in patients I with impaired function of the immune system such as in patients with acute myeloid leukaemia (AML). We investigated the in uence of the patients’ room occu- pancy and the sanitary facilities with regard to the inci- dence of IPA after reconstruction of a haematological ward. This is a retrospective cohort-control study in patients with newly diagnosed AML. Thirty ve patients were treated before and 28 patients in the time after the reconstruction works. The median time of neutropenia was 18.5 days vs. 19.5 days. Twelve patients before and 11 patients after the reconstruction developed IPA (p = 0.794). The incidence of IPA did not decrease after a reduction in the patients’ occupancy and improvement of the sanitary equipment. This study emphasises the presumed importance of optimal physical barriers, e.g. air ltration and/or antimycotic prophylaxis in high-risk patients.