Aspergillus Outbreak in an Intensive Care Unit: Source Analysis with Whole Genome Sequencing and Short Tandem Repeats.

Whole genome sequencing (WGS) is widely used for outbreak analysis of bacteriology and virology but is scarcely used in mycology. Here, we used WGS for genotyping Aspergillus fumigatus isolates from a potential Aspergillus outbreak in an intensive care unit (ICU) during construction work. After detecting the outbreak, fungal cultures were performed on all surveillance and/or patient respiratory samples. Environmental samples were obtained throughout the ICU. WGS was performed on 30 isolates, of which six patient samples and four environmental samples were related to the outbreak, and twenty samples were unrelated, using the Illumina NextSeq 550. A SNP-based phylogenetic tree was created from outbreak samples and unrelated samples. Comparative analysis (WGS and short tandem repeats (STRs), microsatellite loci analysis) showed that none of the strains were related to each other. The lack of genetic similarity suggests the accumulation of Aspergillus spores in the hospital environment, rather than a single source that supported growth and reproduction of Aspergillus fumigatus. This supports the hypothesis that the Aspergillus outbreak was likely caused by release of Aspergillus fumigatus spores during construction work. Indeed, no new Aspergillus cases were observed in the ICU after cessation of construction. This study demonstrates that WGS is a suitable technique for examining inter-strain relatedness of Aspergillus fumigatus in the setting of an outbreak investigation.

The Implementation of a Multidisciplinary Approach for Potential Organ Donors in the Emergency Department.

BACKGROUND: The aim of this study was to evaluate the implementation process of a multidisciplinary approach for potential organ donors in the emergency department (ED) in order to incorporate organ donation into their end-of-life care plans. METHODS: A new multidisciplinary approach was implemented in 6 hospitals in The Netherlands between January 2016 and January 2018. The approach was introduced during staff meetings in the ED, intensive care unit (ICU), and neurology department. When patients with a devastating brain injury had a futile prognosis in the ED, without contraindications for organ donation, an ICU admission was considered. Every ICU admission to incorporate organ donation into end-of-life care was systematically evaluated with the involved physicians using a standardized questionnaire. RESULTS: In total, 55 potential organ donors were admitted to the ICU to incorporate organ donation into end-of-life care. Twenty-seven families consented to donation and 20 successful organ donations were performed. Twenty-nine percent of the total pool of organ donors in these hospitals were admitted to the ICU for organ donation. CONCLUSIONS: Patients with a devastating brain injury and futile medical prognosis in the ED are an important proportion of the total number of donors. The implementation of a multidisciplinary approach is feasible and could lead to better identification of potential donors in the ED.

Small increases in the urinary excretion of glutathione S-transferase A1 and P1 after cardiac surgery are not associated with clinically relevant renal injury.

OBJECTIVE: Cardiac surgery is an important risk factor for the development of acute renal failure. Cytosolic enzymes glutathione S-transferase (GST) A1 and P1 are present selectively in proximal and distal tubular cells, respectively. We determined the extent and site of tubular injury and examined if GST excretion may predict a clinically relevant change in renal function. DESIGN AND SETTING: A prospective, observational study in 84 consecutive patients in the cardiac surgery intensive care unit of the University Medical Centre Nijmegen. MEASUREMENTS AND RESULTS: Urinary GST enzyme excretion was determined 0-4 h and 20-24 h after cardiac surgery by enzyme-linked immunosorbent assay. Data are expressed as median and 5-95% range. Urinary excretion of GSTA1 was increased: 1.25 microg/mmol [0.31-10.20] creatinine at t =0-4 h ( p <0.0001, compared with controls; 0.25 [0.1-0.8]) and returned to normal values at t =20-24 h. Excretion of GSTP1 was 2.11 microg/mmol [0.52-17.82] creatinine ( p <0.0001) at t =0-4 h and remained significantly elevated: 0.84 [0.30-16.86] at t =20-24 h ( p =0.01) compared with controls (0.5 [0.2-1.1]). The ten patients with the highest urinary excretion of GSTA1 or GSTP1 did not demonstrate a different plasma creatinine level on postoperative day 3, compared with the ten patients with the lowest urinary excretion of GSTA1 or GSTP1. CONCLUSION: Uncomplicated cardiac surgery results in a statistically significant increase in the urinary excretion of GSTA1 and GSTP1 as compared with healthy controls, indicating proximal and distal tubular damage. However, this small increase in urinary excretion of GSTs is not associated with clinically relevant renal injury.