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1.
Mycoses ; 64(4): 394-404, 2021 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-33314345

RESUMEN

Outbreaks of fungal infections due to emerging and rare species are increasingly reported in healthcare settings. We investigated a pseudo-outbreak of Rhinocladiella similis in a bronchoscopy unit of a tertiary care teaching hospital in London, UK. We aimed to determine route of healthcare-associated transmission and prevent additional infections. From July 2018 through February 2019, we detected a pseudo-outbreak of R. similis isolated from bronchoalveolar lavage (BAL) fluid samples collected from nine patients who had undergone bronchoscopy in a multispecialty teaching hospital, during a period of 8 months. Isolates were identified by MALDI-TOF mass spectrometry. Antifungal susceptibility testing was performed by EUCAST broth microdilution. To determine genetic relatedness among R. similis isolates, we undertook amplified fragment length polymorphism analysis. To determine the potential source of contamination, an epidemiological investigation was carried out. We reviewed patient records retrospectively and audited steps taken during bronchoscopy as well as the subsequent cleaning and decontamination procedures. Fungal cultures were performed on samples collected from bronchoscopes and automated endoscope washer-disinfector systems. No patient was found to have an infection due to R. similis either before or after bronchoscopy. One bronchoscope was identified to be used among all affected patients with positive fungal cultures. Physical damage was found in the index bronchoscope; however, no fungus was recovered after sampling of the affected scope or the rinse water of automated endoscope washer-disinfectors. Use of the scope was halted, and, during the following 12-month period, Rhinocladiella species were not isolated from any BAL specimen. All pseudo-outbreak isolates were identified as R. similis with high genetic relatedness (>90% similarity) on ALFP analysis. The study emphasises the emergence of a rare and uncommon black yeast R. similis, with reduced susceptibility to echinocandins, in a bronchoscope-related pseudo-outbreak with a potential water-related reservoir. Our findings highlight the importance of prolonged fungal culture and species-level identification of melanised yeasts isolated from bronchoscopy samples. Possibility of healthcare-associated transmission should be considered when R. similis is involved in clinical microbiology samples.


Asunto(s)
Ascomicetos/aislamiento & purificación , Broncoscopios/microbiología , Hospitales de Enseñanza/estadística & datos numéricos , Micosis/epidemiología , Atención Terciaria de Salud/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Antifúngicos/farmacología , Ascomicetos/química , Ascomicetos/efectos de los fármacos , Líquido del Lavado Bronquioalveolar/microbiología , Broncoscopía , Infección Hospitalaria/microbiología , Brotes de Enfermedades , Contaminación de Equipos , Femenino , Humanos , Londres/epidemiología , Masculino , Persona de Mediana Edad , Micosis/transmisión , Estudios Retrospectivos
2.
Mycopathologia ; 181(9-10): 717-21, 2016 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-27193294

RESUMEN

An 88-year-old man, receiving prednisolone for sarcoidosis, presented with a discrete keratotic lesion on the dorsum of his right hand following the placement of an intravenous cannula a month prior to its appearance. Medicopsis romeroi was isolated from the tissue and identified by sequencing the internal transcribed spacer region ITS-1 and the D1-2 fragment of the 28S rDNA gene. Histopathological examination showed fungal hyphae in the internal inflammatory cells layer and within the histocyte-macrophage layer, highly suggestive of deep mycosis. The patient was successfully treated with surgical excision of the cyst. M. romeroi exhibited high MIC values for echinocandin drugs in vitro, but appeared susceptible to newer triazole agents, amphotericin B and terbinafine. This is the first report of a subcutaneous phaeohyphomycotic cyst occurring following the placement of an intravenous cannula. This report highlights the potential role of M. romeroi as an emerging cause of deep, non-mycetomatous infection in immunocompromised patients.


Asunto(s)
Ascomicetos/aislamiento & purificación , Quistes/etiología , Quistes/patología , Huésped Inmunocomprometido , Feohifomicosis/diagnóstico , Feohifomicosis/patología , Anciano de 80 o más Años , Antifúngicos/farmacología , Antifúngicos/uso terapéutico , Cateterismo Periférico/efectos adversos , Quistes/microbiología , ADN de Hongos/química , ADN de Hongos/genética , ADN Ribosómico/química , ADN Ribosómico/genética , ADN Espaciador Ribosómico/química , ADN Espaciador Ribosómico/genética , Desbridamiento , Mano/microbiología , Mano/patología , Histocitoquímica , Humanos , Inmunosupresores/efectos adversos , Inmunosupresores/uso terapéutico , Masculino , Pruebas de Sensibilidad Microbiana , Microscopía , Prednisolona/efectos adversos , Prednisolona/uso terapéutico , ARN Ribosómico 28S/genética , Sarcoidosis/tratamiento farmacológico , Análisis de Secuencia de ADN
3.
Sci Rep ; 10(1): 7965, 2020 05 14.
Artículo en Inglés | MEDLINE | ID: mdl-32409679

RESUMEN

16S ribosomal-ribonucleic acid polymerase chain reaction (PCR) and targeted PCR aid microbiological diagnosis in culture-negative clinical samples. Despite routine clinical use, there remains a paucity of data on their effectiveness across a variety of clinical sample types, and cost-effectiveness. In this 4 year multicentre retrospective observational study, all clinical samples referred for 16S PCR and/or targeted PCR from a laboratory network serving seven London hospitals were identified. Laboratory, clinical, prescribing, and economic variables were analysed. 78/607 samples were 16S PCR positive; pus samples were most frequently positive (29/84; p < 0.0001), and CSF least (8/149; p = 0.003). 210/607 samples had targeted PCR (361 targets requested across 23 organisms) with 43/361 positive; respiratory samples (13/37; p = 0.01) had the highest detection rate. Molecular diagnostics provided a supportive microbiological diagnosis for 21 patients and a new diagnosis for 58. 14/91 patients with prescribing information available and a positive PCR result had antimicrobial de-escalation. For culture-negative samples, mean cost-per-positive 16S PCR result was £568.37 and £292.84 for targeted PCR, equating to £4041.76 and £1506.03 respectively for one prescription change. 16S PCR is more expensive than targeted PCR, with both assisting in microbiological diagnosis but uncommonly enabling antimicrobial change. Rigorous referral pathways for molecular tests may result in significant fiscal savings.


Asunto(s)
Técnicas Microbiológicas , Técnicas de Diagnóstico Molecular , Reacción en Cadena de la Polimerasa , Utilización de Procedimientos y Técnicas , ARN Ribosómico 16S/genética , Técnicas de Tipificación Bacteriana , Enfermedades Transmisibles/diagnóstico , Enfermedades Transmisibles/etiología , Análisis Costo-Beneficio , Humanos , Laboratorios , Londres , Técnicas Microbiológicas/economía , Técnicas Microbiológicas/métodos , Técnicas de Diagnóstico Molecular/economía , Técnicas de Diagnóstico Molecular/métodos , Reacción en Cadena de la Polimerasa/economía , Reacción en Cadena de la Polimerasa/métodos , Utilización de Procedimientos y Técnicas/economía , Utilización de Procedimientos y Técnicas/estadística & datos numéricos , Reproducibilidad de los Resultados , Estudios Retrospectivos , Sensibilidad y Especificidad , Reino Unido
4.
Artículo en Inglés | MEDLINE | ID: mdl-30886704

RESUMEN

Background: Antimicrobial resistance (AMR) is an ecological and economic crisis and stewardship of available antimicrobials is required. Electronic prescribing, where available, enables auditing of practice, yet in order to be efficient and effective in addressing inappropriate antimicrobial prescribing, better use of current and new technological interventions is needed. This retrospective observational evaluation looked at the impact of a commercial clinical decision support system (CDSS) on the workflow of an established antimicrobial stewardship (AMS) team. Material/methods: Clinical, workflow, and pharmaceutical data from 3 months post implementation of CDSS were collated, and compared to the same 3 month periods in preceding years. The evaluation considered total interventions made, the types of intervention made, impact of said interventions, and time spent executing interventions. All antimicrobial data were adjusted for total daily defined doses (DDD) of intravenous antimicrobials. Results: Productivity: In the 3 month evaluation period (Jun-Aug 2016) a total of 264 case reviews resulting in 298 AMS interventions were made. Compared to preceding years where 138 and 169 interventions were made (2013 and 2014 respectively). In 2013 49% of interventions were stopping medication and 30% change of therapy based on cultures and sensitivities compared to 25 and 17% in 2016. In contrast to previous years', the CDSS instead enabled a greater number of dose/drug optimisation (13%), escalation of antimicrobials (12%) and intravenous (IV) to oral switch (11%) interventions.Patient Identification: Despite increased patient numbers post-CDSS, on average 46 min per day was spent compiling a patient list for review, compared to 59 min in 2014. The use of CDSS facilitated 15 interventions/1000DDD, compared to pre-intervention (9.4/1000DDD in 2013; 11.5/1000DDD in 2014). Conclusions: Initial evaluation of the impact of this CDSS on AMS at the organisation has demonstrated effectiveness in terms of case finding, AMS team productivity, and workflow auditing. More importantly, patient infection management has been optimised with a shift in the emphasis of AMS interventions. It has contributed to the success of the healthcare provider achieving nationally set remunerated AMS targets.


Asunto(s)
Antibacterianos/administración & dosificación , Programas de Optimización del Uso de los Antimicrobianos/métodos , Sistemas de Apoyo a Decisiones Clínicas/organización & administración , Administración Intravenosa , Administración Oral , Prescripciones de Medicamentos , Humanos , Prescripción Inadecuada , Pautas de la Práctica en Medicina/estadística & datos numéricos , Estudios Retrospectivos
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