Aerosol Transmission of Aspergillus fumigatus in Cystic Fibrosis Patients in the Netherlands.

We collected sputum samples and cough plates from 15 cystic fibrosis patients in the Netherlands who were colonized with Aspergillus fumigatus; we recovered A. fumigatus of the same genotype in cough aerosols and sputum samples from 2 patients. The belief that transmission of A. fumigatus from cystic fibrosis patients does not occur should be reconsidered.

Microsatellite Typing of Aspergillus flavus Strains in a Tunisian Onco-hematology Unit.

Aspergillus flavus is the most common species associated with invasive aspergillosis in Tunisia. The molecular epidemiology of the species is poorly documented. We used five highly discriminative microsatellite markers for the genotyping of clinical and hospital environmental A. flavus strains to assess whether IA could be hospital-acquired in the onco-hematology unit of the Farhat Hached teaching hospital of Sousse, Tunisia. The genotyping of 18 clinical isolates, collected from sputa of 17 acute leukemia patients, and 81 isolates, collected in these patients' hospital environment and food, identified 57 isolates that were grouped in 10 clones, each of them including 2-17 isolates. The remaining 42 isolates showed a unique genotype. Two main transmission scenarios were observed: (1) the same clone was isolated from different patients; (2) the same clone was isolated from a patient, its hospital environment and/or food. These findings strongly suggest the occurrence of hospital-acquired A. flavus infection/colonization in the investigated onco-hematology unit.

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.

Bayesian development of a dose-response model for Aspergillus fumigatus and invasive aspergillosis.

Invasive aspergillosis (IA) is a major cause of mortality in immunocompromized hosts, most often consecutive to the inhalation of spores of Aspergillus. However, the relationship between Aspergillus concentration in the air and probability of IA is not quantitatively known. In this study, this relationship was examined in a murine model of IA. Immunosuppressed Balb/c mice were exposed for 60 minutes at day 0 to an aerosol of A. fumigatus spores (Af293 strain). At day 10, IA was assessed in mice by quantitative culture of the lungs and galactomannan dosage. Fifteen separate nebulizations with varying spore concentrations were performed. Rates of IA ranged from 0% to 100% according to spore concentrations. The dose-response relationship between probability of infection and spore exposure was approximated using the exponential model and the more flexible beta-Poisson model. Prior distributions of the parameters of the models were proposed then updated with data in a Bayesian framework. Both models yielded close median dose-responses of the posterior distributions for the main parameter of the model, but with different dispersions, either when the exposure dose was the concentration in the nebulized suspension or was the estimated quantity of spores inhaled by a mouse during the experiment. The median quantity of inhaled spores that infected 50% of mice was estimated at 1.8 × 10(4) and 3.2 × 10(4) viable spores in the exponential and beta-Poisson models, respectively. This study provides dose-response parameters for quantitative assessment of the relationship between airborne exposure to the reference A. fumigatus strain and probability of IA in immunocompromized hosts.

Molecular sub-typing suggests that the environment of rehabilitation centers may be a potential source of Aspergillus fumigatus infecting rehabilitating seabirds.

Aspergillosis remains a major cause of infection-related avian mortality in birds that are debilitated and undergoing rehabilitation for release into the wild. This study was designed to understand the source of avian aspergillosis in seabirds undergoing rehabilitation at selected northern California aquatic bird rehabilitation centers. Air, surface and water sampling was performed between August 2007 and July 2008 in three such centers and selected natural seabird loafing sites. Average air Aspergillus fumigatus counts were at least nine times higher in samples obtained from the rehabilitation sites (M = 7.34, SD = 9.78 CFU/m(3)), when compared to those found at natural sites (M = 0.76, SD = 2.24 CFU/m(3)), t (205) = -5.99, P < 0.001. A total of 37 A. fumigatus isolates from birds with confirmed aspergillosis and 42 isolates from environmental samples were identified using both morphological and molecular methods, and subsequently sub-typed using an eight-locus microsatellite panel with the neighbor joining algorithm. Results of the study demonstrated the presence of five clonal groups, 13 genotypically related clusters, and 59 distinct genotypes. Six of the 13 genotypically related clusters contained matching genotypes between clinical isolates and local environmental isolates from the rehabilitation center in which these birds were housed. We present evidence that the environment of rehabilitation centers may be a source for A. fumigatus infection in rehabilitated seabirds.

[Invasive fungal infection in solid organ transplant]. / Infección fúngica invasora en el trasplante de órgano sólido.

Invasive fungal infections (IFI) represent a serious threat for patients undergoing solid organ transplantation (SOT). IFI in SOT has a significant incidence and mortality not due to negligence. The management of IFI in SOT involves specific recommendations and has been individualized to the type of transplant and patient. The current review presents an overview of epidemiology, diagnosis, treatment and prevention of IFI in TOS. Depending on risk factors for different IFIs and transplant type, this paper includes the main recommendations based on previous publications and on the opinion of the authors on the prophylaxis and treatment of these patients. These recommendations highlight epidemiology changes and the emergence of new antifungals. The current document has focused mainly on Candidaspp. and Aspergillusspp., with a special mention to the rest of yeasts and moulds that are common in SOT.

A novel case of canine disseminated aspergillosis following mating.

An intact bitch with a history of mating was presented with severe lameness and a vulvar discharge. A mixed lytic, proliferative tibial lesion and open pyometra were diagnosed. Bone biopsy and uterine culture revealed disseminated aspergillosis. This is the first report of Aspergillus pyometra with dissemination following mating in the dog.

Aspergillosis: nosocomial or community-acquired?

Discrimination between nosocomial and community infections is important for investigation and prevention. Nosocomial and hospital-acquired infections require appropriate hospital control measures to avert additional cases. Nosocomial infections (NI) occur during hospitalization or are caused by microorganisms acquired during hospital stay. Such infections should not be evident when patients are admitted to the hospital. Furthermore, the definition of NI is based on epidemiological criteria, such as the time lapse between admission and onset, or microbiological criteria. This definition might be difficult to apply to invasive aspergillosis (IA) which often afflicts patients with severe immunosuppression or transplantation. Identification of the source may be difficult which could arise outside or inside the hospital. Another significant issue is the lack of valid and reproducible data on the incubation period. The incubation duration of IA is influenced by different individual or environmental determinants, including the severity of immunosuppression and air quality. The criteria of causality are also a means of discussing the contribution of hospital vs. community determinants of IA. The definition of nosocomial IA remains difficult. A better understanding of early events related to IA onset will help to prevent this disease for which the prognosis remains negative.

Donor-derived aspergillosis from use of a solid organ recipient as a multiorgan donor.

The growing need for organs and the scarcity of donors has resulted in an increased use of extended criteria donors. We report a case where a recipient of a cardiac graft was used as an organ donor. Death of the recipient occurred 9 days after transplantation and was attributed to presumed cerebral hemorrhage, which post mortem was diagnosed as invasive aspergillosis of the brain. One recipient of a kidney transplant lost the graft due to infection with Aspergillus fumigatus, whereas prompt initiation of therapy successfully prevented disseminated aspergillosis in the other recipients. Despite the pressure to extend the use of organs by lowering the acceptance criteria, organs should only be accepted if the cause of death of the donors is unequivocally explained.

Comparison of two control measures of weatherstripping in reducing blowing dust during hospital renovations.

Hospital renovation projects pose risks of invasive infection by fungi from dust that is blown about during the period in question. Control measures to reduce the amount of dust during hospital renovation are thus necessary. Currently, no study has compared different control measures for effectiveness through more than one period of renovation. In this study, we examined the capacities of two control measures of weatherstripping (0.15 mm poly film and adhesive tape) to reduce the amount of blowing dust during two different hospital renovations (in 2008 and 2009). The amount of dust in the air of the hospital before and during the renovation was measured about once a week in both 2008 and 2009, and the between-year and within-year differences were tested. Our study revealed that the weatherstripping used in 2009 (adhesive tape) was significantly more effective than the measures taken in 2008 (0.15 mm poly film) to reduce the amount of dust during the renovations (p < 0.001), while in both years the amount of dust became significantly higher during the renovations than before the renovations. Differences in the effectiveness of weatherstripping during renovations between floors of the hospital were not significant in both 2008 and 2009. The number of Aspergillus-positive samples did not significantly increase compared with the number observed before the start of the hospital renovations (2006-2007) in 2008 and 2009, respectively. The weatherstripping potentially reduced the associated risk of airborne fungal infection.

Are positive-pressure ventilation lobby rooms effective for protective and source isolation?

High-efficiency particulate air supplied to a positive-pressure ventilation lobby (PPVL) in isolation rooms offers the dual advantage of protective and source isolation. This study demonstrates the in-use validity of PPVL rooms for protective isolation of patients. Of the 48 PPVL air samples investigated, Aspergillus fumigatus was detected from only one (2%) sample. Local and remote monitoring of the PPVL rooms is essential for the safety of patients and healthcare workers. Remote and point-of-use engineering controls are essential for ongoing ventilation monitoring, but this should be complemented by visual inspection of the isolation suite. Periodic microbiological monitoring should also be considered with other control measures.

[Aspergillosis]. / Aspergillose.

Aspergillosis, due to moulds belonging to the genus Aspergillus, occurs in patients with residual lung cavities. The clinical manifestations are determined by the host immune response, ranging from a local inflammatory response to the systemic dissemination. Haemoptysis is the most common symptom. The chest X-ray reveals a round mass with a radio-lucent crescent of air. The antifungal treatments are successful.

Molecular characterization of Aspergillus fumigatus isolated from raw cow milk in Argentina: Molecular typing of A. fumigatus from raw cow milk.

Aspergillus fumigatus, the major etiological agent of human and animal aspergillosis, is a gliotoxinogenic species into section Fumigati commonly found in contaminated animal environments. In dairy herds, exposed areas of lactating cows, as mammalian glandule, can be easily contaminated by them. This study was aimed to identify A. fumigatus sensu lato strains (identified based on morphology) isolated from raw cow milk at species level, by morphological and molecular techniques, and to estimate their genetic variability. Forty-five A. fumigatus strains showed similar RAPD profiles (generated with PELF and URP1F primers) to each other and to A. fumigatus sensu stricto reference strains; also, they were almost identical to clinical human and feed-borne A. fumigatus strains included in the assay, since their similarity coefficient ranged from 0.7 to 1.00. Therefore, all strains were characterized as belonging to A. fumigatus sensu stricto species. This result was supported by sequencing the benA gene of selected strains and by maximum parsimony analysis. In addition, RAPD fingerprinting demonstrated intra-specific genetic variability into the A. fumigatus sensu stricto cluster. The results found in this study strengthen the fact that A. fumigatus sensu stricto is the predominant species in the Aspergillus section Fumigati found in animal environments such as dairy herd environments, while other species such as A. novofumigatus, A. fumigatiaffinis, A. udagawae and A. lentulus may be rarely isolated. Since no differences between animal and human strains were observed they can become pathogenic also for farm handlers'. Moreover, the presence of A. fumigatus sensu stricto in raw cow milk is probably a very important risk factor since milk and its by-products are generally indented for human consumption, then gliotoxin could be transferred to them.

[Zygomycosis after hematogeneic stem cell transplantation--a current problem?]. / Zygomykosen nach Blutstammzelltransplantation--ein aktuelles Problem?

Zygomycoses are rare but often lethal mold infections predominantly affecting immunocompromised patients. Over the last years, several tertiary-care cancer centers reported an increase in the incidence of zygomycete infections in allogeneic blood stem cell transplant recipients. These observations are based on a small number of patients and should be considered in the context of a decades-long increase of mold infection rates. Diagnostic obstacles, including the difficult discrimination from the tenfold more frequent aspergilloses, may confound the reported incidences of zygomycete infections. These may be due to changes in frequency, severity and management of graft-versus-host disease promoting filamentous fungal infections, including zygomycoses. Hospitals applying long-term voriconazole prophylaxis in high-risk patients report a significant decrease in aspergillosis rates since the drug became available in 2001. The observation of increased frequencies of zygomycete infections during this period of time is not based on prospective evaluations. Therefore, the causes of these findings remain a matter of debate. Current multicenter trials on antifungal prophylaxis in high-risk patients promise to generate reliable data on the protective effect of antifungals active against molds, and the incidence of zygomycete infections in a controlled setting.

Isolated cardiac aspergillosis after bone marrow transplantation.

A 15-year-old girl developed isolated cardiac aspergillosis after allogeneic bone marrow transplantation. Predisposing factors included severe graft-vs-host disease with gastrointestinal tract involvement and immunosuppressive therapy including cyclosporine. The patient died of cardiopulmonary failure 11 weeks after transplantation.

Cluster of cases of invasive aspergillosis in a transplant intensive care unit: evidence of person-to-person airborne transmission.

In October 1998, a patient developed deep surgical-site and organ-space infection with Aspergillus fumigatus 11 days after undergoing liver retransplantation; subsequently, 2 additional patients in the transplant intensive care unit had invasive pulmonary infection with A. fumigatus diagnosed. It was determined that debriding and dressing wounds infected with Aspergillus species may result in aerosolization of spores and airborne person-to-person transmission.

Pseudoaneurysm of the iliac artery secondary to Aspergillus infection in two recipients of kidney transplants from the same donor.

The authors report 2 cases of patients who underwent cadaveric renal transplantation from the same donor in a multiorgan extraction procedure. Both cases showed, during the first 6 months posttransplantation, a worsening in renal graft function and signs of ischemia in the homolateral lower limb. One of the cases was preceded by pain in the sciatic region. In imaging tests, a pseudoaneurysm was detected in the iliac artery in both patients. Grafts had to be removed, and the iliac arteries were ligated with posterior isolation of Aspergillus spp from the arterial vessels but not from the renal tissue. Besides surgery, medical treatment with liposomal amphotericin B was initiated with a different outcome in each patient: patient A died, whereas patient B recovered. The absence of Aspergillus spp infection in liver and heart recipients ruled out a donor-transmitted infection. The graft placements were carried out in different operating rooms, which rules out contamination during the transplantation process. All of this leads us to conclude that the infection must have occurred during the preservation phase of the kidney.

Allergic bronchopulmonary aspergillosis associated with smoking moldy marihuana.

A 27-year-old man who habitually smoked marihuana developed clinical, laboratory, and radiologic findings consistent with allergic bronchopulmonary aspergillosis. Culture of the marihuana obtained from the patient's source yielded heavy mixed growths of Aspergillus. Treatment with corticosteroids was effective.

Transmission of invasive aspergillosis from a subclinically infected donor to three different organ transplant recipients.

OBJECTIVE: To describe a cluster of donor-transmitted cases of invasive aspergillosis. DESIGN: Case series of epidemiologically linked cases of invasive aspergillosis. SETTING: Two tertiary care centers with solid-organ transplant programs. PATIENTS: Two kidney recipients, one heart recipient, and the single donor. MEASUREMENTS: Routine clinical, microbiological, and pathologic investigation as dictated for patient care. Epidemiologic analysis to establish linkage among cases. RESULTS: Three allografts (two kidneys and a heart) from a single donor transmitted invasive aspergillosis to the recipients. Three weeks after transplantation, the two kidney recipients had fever and urine cultures positive for Aspergillus fumigatus. The infected kidneys had multiple Aspergillus abscesses and had to be removed to cure the patients. The heart recipient had a negative workup when a diagnosis of aspergillosis was made for the kidney recipients but presented three months later with aspergillus endocarditis with hematogenous spread to the eyes and to the skin. Treatment included eye surgery, aortic valve replacement, and antifungal therapy; control of infection ensued. The donor was intensely immunosuppressed (17 days post-liver transplantation with death from intracerebral bleeding) but had no clinical or autopsy evidence of aspergillosis. Donor tracheal secretions obtained at the time of organ harvest later grew A fumigatus. CONCLUSION: Expanded criteria for organ donation have to be balanced against infectious risk to organ recipients. A fumigatus can be transmitted from a subclinically infected donor to solid-organ transplant recipients.