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Postoperative aspergillosis. Alessandro C. Pasqualotto School of Medicine, The University of Manchester Wythenshawe Hospital, UK. Case report. Male, 70 year-old Elective aortic valve replacement. www.aspergillus.man.ac.uk/secure/casehistories/case048.htm. Case report. Male, 70 year-old

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slide1

Postoperative aspergillosis

Alessandro C. PasqualottoSchool of Medicine, The University of ManchesterWythenshawe Hospital, UK

slide2

Case report

  • Male, 70 year-old
  • Elective aortic valve replacement

www.aspergillus.man.ac.uk/secure/casehistories/case048.htm

slide3

Case report

  • Male, 70 year-old
  • Elective aortic valve replacement
  • 4 months: fatigue and  physical endurance

www.aspergillus.man.ac.uk/secure/casehistories/case048.htm

slide4

Case report

  • Male, 70 year-old
  • Elective aortic valve replacement
  • 4 months: fatigue and  physical endurance
  • 7 months: profuse diarrhoea

www.aspergillus.man.ac.uk/secure/casehistories/case048.htm

slide5

Case report

  • Male, 70 year-old
  • Elective aortic valve replacement
  • 4 months: fatigue and  physical endurance
  • 7 months: profuse diarrhoea
  • One week later: chills + fever
  • 19,000 x 106 leukocytes.

www.aspergillus.man.ac.uk/secure/casehistories/case048.htm

slide6

Case report

  • TEE: large aortic vegetation

www.aspergillus.man.ac.uk/secure/casehistories/case048.htm

slide7

Case report

  • TEE: large aortic vegetation
  • Blood cultures: negative

www.aspergillus.man.ac.uk/secure/casehistories/case048.htm

slide8

Case report

  • TEE: large aortic vegetation
  • Blood cultures: negative
  • Working diagnosis: viridans strep endocarditis

www.aspergillus.man.ac.uk/secure/casehistories/case048.htm

slide9

Case report

  • TEE: large aortic vegetation
  • Blood cultures: negative
  • Working diagnosis: viridans strep endocarditis
  • Discharged on ceftriaxone and metronidazole

www.aspergillus.man.ac.uk/secure/casehistories/case048.htm

slide10

Case report

  • TEE: large aortic vegetation
  • Blood cultures: negative
  • Working diagnosis: viridans strep endocarditis
  • Discharged on ceftriaxone and metronidazole
  • Readmitted for fever and CHF

www.aspergillus.man.ac.uk/secure/casehistories/case048.htm

slide11

Case report

  • TEE: large aortic vegetation
  • Blood cultures: negative
  • Working diagnosis: viridans strep endocarditis
  • Discharged on ceftriaxone and metronidazole
  • Readmitted for fever and CHF
  • Vancomycin and doxycycline were added.

www.aspergillus.man.ac.uk/secure/casehistories/case048.htm

slide12

Case report

  • After 2 days: hemiparesis and aphasia

www.aspergillus.man.ac.uk/secure/casehistories/case048.htm

slide13

Case report

  • After 2 days: hemiparesis and aphasia
  • He died three days later

www.aspergillus.man.ac.uk/secure/casehistories/case048.htm

slide14

Case report

  • After 2 days: hemiparesis and aphasia
  • He died three days later
  • Autopsy:
    • Massive cerebral haemorrhage
    • Embolus containing Aspergillusin the right middle cerebral artery

www.aspergillus.man.ac.uk/secure/casehistories/case048.htm

slide15

Case report

  • After 2 days: hemiparesis and aphasia
  • He died three days later
  • Autopsy:
    • Massive cerebral haemorrhage
    • Embolus containing Aspergillus in the right middle cerebral artery
    • Endocarditis lesion: multiple hyphae

www.aspergillus.man.ac.uk/secure/casehistories/case048.htm

slide16

Case report

  • After 2 days: hemiparesis and aphasia
  • He died three days later
  • Autopsy:
    • Massive cerebral haemorrhage
    • Embolus containing Aspergillus in the right middle cerebral artery
    • Endocarditis lesion: multiple hyphae
    • No other site of infection was found.

www.aspergillus.man.ac.uk/secure/casehistories/case048.htm

slide19

Aspergillosis

  • Aspergillus are ubiquitous
    • Soil, water and decaying vegetation
slide20

Aspergillosis

  • Aspergillus are ubiquitous
    • Soil, water and decaying vegetation
  • Primarily acquired by inhalation
slide21

Aspergillosis

  • Aspergillus are ubiquitous
    • Soil, water and decaying vegetation
  • Primarily acquired by inhalation
  • Nosocomial aspergillosis typically affects immunocompromised patients.
slide23

The spectrum of aspergillosis

Frequency of aspergillosis

www.aspergillus.man.ac.uk

slide24

The spectrum of aspergillosis

Frequency of aspergillosis

Immune system

www.aspergillus.man.ac.uk

slide25

The spectrum of aspergillosis

Frequency of aspergillosis

Disfunction

Immune system

www.aspergillus.man.ac.uk

slide26

Acute IA

The spectrum of aspergillosis

Frequency of aspergillosis

Disfunction

Immune system

www.aspergillus.man.ac.uk

slide27

Acute IA

The spectrum of aspergillosis

Subacute IA

Frequency of aspergillosis

Disfunction

Immune system

www.aspergillus.man.ac.uk

slide28

Acute IA

The spectrum of aspergillosis

Subacute IA

Frequency of aspergillosis

Tracheobronchitis

Fungus ball

Chronic cavitary

Chronic fibrosing

Disfunction

Normal

.

Immune system

www.aspergillus.man.ac.uk

slide29

Acute IA

ABPA

Allergic sinusitis

The spectrum of aspergillosis

Subacute IA

Frequency of aspergillosis

Tracheobronchitis

Fungus ball

Chronic cavitary

Chronic fibrosing

Disfunction

Normal

Hyper immune

.

Immune system

www.aspergillus.man.ac.uk

slide31

Review of the world literature

  • Medline, LILACS and EMBASE
slide32

Review of the world literature

  • Medline, LILACS and EMBASE
  • References were reviewed
slide33

Review of the world literature

  • Medline, LILACS and EMBASE
  • References were reviewed
  • Conference abstracts (www.aspergillus.man.ac.uk)
slide34

Review of the world literature

  • Medline, LILACS and EMBASE
  • References were reviewed
  • Conference abstracts (www.aspergillus.man.ac.uk)
  • Only cases of proven or probable aspergillosis were reviewed.
slide35

Review of the world literature

  • Not included:
    • Primary cutaneous aspergillosis
slide36

Review of the world literature

  • Not included:
    • Primary cutaneous aspergillosis

Neonate

Andresen J, et al. Acta Paediatr 2005; 94: 761-2.

slide37

Review of the world literature

  • Not included:
    • Primary cutaneous aspergillosis

Neonate

Diabetes mellitus

slide38

Review of the world literature

  • Not included:
    • Primary cutaneous aspergillosis

Neonate

Diabetes mellitus

Burn patient

www.aspergillus.man.ac.uk

slide39

Review of the world literature

  • Not included:
    • Infections associated with intravascular devices
slide40

Review of the world literature

  • Not included:
    • Infections associated with intravascular devices

Neutropenia

slide41

Review of the world literature

  • Not included:
    • Infections associated with intravascular devices

Neutropenia

HIV

slide42

Literature review

  • More than 500 cases were included
slide43

Literature review

  • More than 500 cases were included
  • Heart surgery: 188
  • Dental surgery: > 100
  • Ophthalmologic surgery: > 90
  • Wound infections: 22
  • Neurosurgery: 25
  • Vascular prosthetic surgery: 22
  • Orthopaedic surgery: 42
  • Bronchial infections: 30
  • Abdominal surgery: 10
  • Mediastinitis: 11
  • Breast surgery: 5
  • Pleural aspergillosis: 1
slide45

Endocarditis and aortitis

  • 124 cases 40 other cases
slide46

Endocarditis and aortitis

  • 124 cases
  • Male gender: 69.9%
slide47

Endocarditis and aortitis

  • 124 cases
  • Male gender: 69.9%
  • Median age: 43.5 years-old (0.8 to 71)
slide48

Endocarditis and aortitis

  • 124 cases
  • Male gender: 69.9%
  • Median age: 43.5 years-old (0.8 to 71)
  • Main valves:
    • Aortic: involved in 60.5%
    • Mitral: 30.6%
slide49

Endocarditis and aortitis

  • 124 cases
  • Male gender: 69.9%
  • Median age: 43.5 years-old (0.8 to 71)
  • Main valves:
    • Aortic: involved in 60.5%
    • Mitral: 30.6%
  • Median 2.7 months after surgery (<1 to > 12).
slide50

Key features

  • Absence of immunosuppression
slide51

Key features

  • Absence of immunosuppression
  • No bronchopulmonary aspergillosis
slide52

Key features

  • Absence of immunosuppression
  • No bronchopulmonary aspergillosis
  • Postoperative course consistent with culture-negative endocarditis
slide53

Key features

  • Absence of immunosuppression
  • No bronchopulmonary aspergillosis
  • Postoperative course consistent with culture-negative endocarditis
  • Propensity to late embolisation.
slide54

Aspergillus species

  • A. fumigatus: 58.7%
slide55

Aspergillus species

  • A. fumigatus: 58.7%
  • A. terreus: 12.5%
slide56

Aspergillus species

  • A. fumigatus: 58.7%
  • A. terreus: 12.5%
  • A. flavus: 11.2%
  • A. niger: 11.2%
  • A. glaucus: 2.5%
  • A. clavatus: 1.2%
  • A. ustus: 1.2%
  • A. sydowi: 1.2%
  • A. spp: 20.0%
slide58

Large vegetations

Hosking MC, et al. Ann Thorac Surg 1995; 59: 1015-7.

slide59

Diagnosis

  • Antemortem diagnosis: 43.5%
slide60

Diagnosis

  • Antemortem diagnosis: 43.5%
    • Vegetation, valve/graft examination: 23.4%
slide61

Diagnosis

  • Antemortem diagnosis: 43.5%
    • Vegetation, valve/graft examination: 23.4%
    • Embolic material: 16.9%
slide62

Diagnosis

  • Antemortem diagnosis:43.5%
    • Vegetation, valve/graft examination: 23.4%
    • Embolic material: 16.9%
    • Positive blood culture: 6.4% (n=8)
slide63

Diagnosis

  • Antemortem diagnosis:43.5%
    • Vegetation, valve/graft examination: 23.4%
    • Embolic material: 16.9%
    • Positive blood culture: 6.4% (n=8)
    • Serology/precipitins: 2.4%.
slide64

Diagnosis

  • Other diagnostic methods?
slide65

Diagnosis

  • Other diagnostic methods?

Pemán J, et al. 2nd TIMM, Berlin 2005. P-048.

slide66

Diagnosis

  • Other diagnostic methods?

Negative galactomannan

(ELISA)

Pemán J, et al. 2nd TIMM, Berlin 2005. P-048.

slide67

Mortality

  • Overall mortality:92.7%
slide68

Mortality

  • Overall mortality: 92.7%
  • Antemortem diagnosis:mortality 83.0%

(p<0.0001)

slide69

Mortality

  • Overall mortality: 92.7%
  • Antemortem diagnosis: mortality 83.0%

(p<0.0001)

  • Surgical treatment: 80.9%.
slide72

Aspergillus graft infection

  • n=22
  • Almost all cases: immunocompetent males
slide73

Aspergillus graft infection

  • n=22
  • Almost all cases: immunocompetent males
  • Median 8 months after surgery
slide74

Aspergillus graft infection

  • n=22
  • Almost all cases: immunocompetent males
  • Median 8 months after surgery
    • Candida graft infections: usually < 6 weeks
slide75

Aspergillus graft infection

  • n=22
  • Almost all cases: immunocompetent males
  • Median 8 months after surgery
    • Candida graft infections: usually < 6 weeks
  • Similar to S. epidermidisinfection
slide76

Aspergillus graft infection

  • n=22
  • Almost all cases: immunocompetent males
  • Median 8 months after surgery
    • Candida graft infections: usually < 6 weeks
  • Similar to S. epidermidis infection
  • Suture line of a previous aortotomy.
slide79

Definitive diagnostic procedures

  • Culture of the excised aortic graft
slide80

Definitive diagnostic procedures

  • Culture of the excised aortic graft
  • Culture of peripheral embolus
slide81

Definitive diagnostic procedures

  • Culture of the excised aortic graft
  • Culture of peripheral embolus
  • Biopsy of the contiguously affected vertebral disk.
slide82

Treatment

  • Effective treatment: removal of the graft
slide83

Treatment

  • Effective treatment: removal of the graft
  • Systemic antifungal therapy
slide84

Treatment

  • Effective treatment: removal of the graft
  • Systemic antifungal therapy
  • Extra-anatomic bypass through a clean field.
slide86

Case report

  • Female, 16 year-old
  • Elective neurosurgery for Chiari I malformation

www.aspergillus.man.ac.uk/secure/casehistories/case050.htm

slide87

Case report

  • Female, 16 year-old
  • Elective neurosurgery for Chiari I malformation
  • Long course of dexamethasone

www.aspergillus.man.ac.uk/secure/casehistories/case050.htm

slide88

Case report

  • Female, 16 year-old
  • Elective neurosurgery for Chiari I malformation
  • Long course of dexamethasone
  • Clinical deterioration
    • Vancomycin and cefotaxime
    • Dexamethasone dose was increased.

www.aspergillus.man.ac.uk/secure/casehistories/case050.htm

slide89

Case report

  • CSF culture (day 18): few colonies of A. fumigatus.

www.aspergillus.man.ac.uk/secure/casehistories/case050.htm

slide91

Case report

  • Symptoms persisted

www.aspergillus.man.ac.uk/secure/casehistories/case050.htm

slide92

Case report

  • Symptoms persisted
  • Wound exploration: sutures had dehisced

www.aspergillus.man.ac.uk/secure/casehistories/case050.htm

slide93

Case report

  • Symptoms persisted
  • Wound exploration: sutures had dehisced
  • Cultures again revealed A. fumigatus
  • Amphotericin B was started (day 28)

www.aspergillus.man.ac.uk/secure/casehistories/case050.htm

slide94

Case report

  • Symptoms persisted
  • Wound exploration: sutures had dehisced
  • Cultures again revealed A. fumigatus
  • Amphotericin B was started (day 28)
  • Symptoms did not improve
  • Dural graft was removed.

www.aspergillus.man.ac.uk/secure/casehistories/case050.htm

slide95

Case report

  • A. fumigatus in the surgical specimens

www.aspergillus.man.ac.uk/secure/casehistories/case050.htm

slide96

Case report

  • A. fumigatus in the surgical specimens
  • She died 2 months after the 1st surgery

www.aspergillus.man.ac.uk/secure/casehistories/case050.htm

slide97

Case report

  • A. fumigatus in the surgical specimens
  • She died 2 months after the 1st surgery
  • Autopsy:
    • Abundant hyphae in the origin of the basilar artery and bilateral vertebral arteries
    • Multifocal transmural destruction of arterial walls

www.aspergillus.man.ac.uk/secure/casehistories/case050.htm

slide98

Case report

  • A. fumigatus in the surgical specimens
  • She died 2 months after the 1st surgery
  • Autopsy:
    • Abundant hyphae in the origin of the basilar artery and bilateral vertebral arteries
    • Multifocal transmural destruction of arterial walls
    • No other focus of aspergillosis was found.

www.aspergillus.man.ac.uk/secure/casehistories/case050.htm

slide101

Aspergillosis after neurosurgery

  • n=25
  • Male sex: 44.0%
  • Steroids:52.0%
slide102

Aspergillosis after neurosurgery

  • n=25
  • Male sex: 44.0%
  • Steroids: 52.0%
  • All proven cases: A. fumigatus.
slide103

Aspergillosis after neurosurgery

  • Median 3 months after surgery (<1 to > 12)
slide104

Aspergillosis after neurosurgery

  • Median 3 months after surgery (<1 to > 12)
  • Different presentations
    • Meningitis
    • CNS abscess
    • Mycotic aneurisms
    • Infarction.
slide105

Aspergillosis after neurosurgery

  • Antemortem diagnosis:64.0%
slide106

Aspergillosis after neurosurgery

  • Antemortem diagnosis:64.0%
    • Abscess examination: 36.0%

www.aspergillus.man.ac.uk/secure/image_library/invpulmonaryasp/cerebralaspkh.htm

slide107

Aspergillosis after neurosurgery

  • Antemortem diagnosis:64.0%
    • Abscess examination: 36.0%
    • Culture of CSF:20.0%
slide108

Aspergillosis after neurosurgery

  • Antemortem diagnosis: 64.0%
    • Abscess examination: 36.0%
    • Culture of CSF: 20.0%
  • Mortality: 68.0%.
slide109

Trans-sphenoidal surgery

Endo T, et al. Surg Neurol 2001; 56: 195-200.

slide111

Definitions

  • Skin or subcutaneous tissue of the incision
slide112

Definitions

  • Skin or subcutaneous tissue of the incision
  • When both superficial and deep incision sites: classified as deep surgical site infection
slide113

Definitions

  • Skin or subcutaneous tissue of the incision
  • When both superficial and deep incision sites: classified as deep surgical site infection
  • Similar to CDC’s criteria for SSI.
slide114

Definitions

  • The wound itself had to be non-healing with standard antibiotics, and other pathogens were absent or minimally presented
slide115

Definitions

  • The wound itself had to be non-healing with standard antibiotics, and other pathogens were absent or minimally presented
  • Topographic relation between the surgery and the infection
slide116

Definitions

  • The wound itself had to be non-healing with standard antibiotics, and other pathogens were absent or minimally presented
  • Topographic relation between the surgery and the infection
  • n=22.
slide117

The first case reported

  • 1933

Frank L, Alton OM. JAMA 1933; 100: 2007-8.

slide118

The first case reported

  • 1933
  • Female, 40 year-old
  • Operated on for an abdominal tumour

Frank L, Alton OM. JAMA 1933; 100: 2007-8.

slide119

The first case reported

  • 1933
  • Female, 40 year-old
  • Operated on for an abdominal tumour
  • After 16 days: ulcer under the dressing
  • No systemic manifestations

Frank L, Alton OM. JAMA 1933; 100: 2007-8.

slide120

The first case reported

  • 1933
  • Female, 40 year-old
  • Operated on for an abdominal tumour
  • After 16 days: ulcer under the dressing
  • No systemic manifestations
  • A. niger grew in the surgical dressings covered with a dark powder.

Frank L, Alton OM. JAMA 1933; 100: 2007-8.

slide121

Particularities

  • Median 17 days after surgery (<7 to 180)
slide122

Particularities

  • Median 17 days after surgery (<7 to 180)
  • Many patients were immunosuppressed
slide123

Particularities

  • Median 17 days after surgery (<7 to 180)
  • Many patients were immunosuppressed
  • Aspergillus species:
    • A. fumigatus: 42.1%
    • A. flavus: 36.8%
    • A. niger: 10.5%
    • A. spp: 10.5%
slide124

Risk of dissemination

  • Aggressive combined medical therapy and debridement is required for all patients.
slide125

Outbreaks

  • Outbreak of wound aspergillosis
    • Contamination during hospital construction of the outside packages of dressing supplies

Bryce EA, et al. Infect Control Hosp Epidemiol 1996; 17: 170-2.

slide126

Outbreaks

  • Outbreak of wound aspergillosis
    • Contamination during hospital construction of the outside packages of dressing supplies
  • Outbreaks of cutaneous aspergillosis
    • Wound dressing and tape should be cultured

Bryce EA, et al. Infect Control Hosp Epidemiol 1996; 17: 170-2.

slide127

Outbreaks

  • Outbreak of wound aspergillosis
    • Contamination during hospital construction of the outside packages of dressing supplies
  • Outbreaks of cutaneous aspergillosis
    • Wound dressing and tape should be cultured
  • A. flavus sternal wound infection coinciding with hospital renovation activities.

Bryce EA, et al. Infect Control Hosp Epidemiol 1996; 17: 170-2.

slide128

Risk factors

  • Chronic lung disease
    • Independent risk factor for A. fumigatus sternal wound infection after open-heart surgery

Richet HM, et al. Am J Epidemiol 1992; 135: 48-58.

slide129

Risk factors

  • Chronic lung disease
    • Independent risk factor for A. fumigatus sternal wound infection after open-heart surgery
    • A. fumigatus grew at the same time from the bronchial washing of one patient

Richet HM, et al. Am J Epidemiol 1992; 135: 48-58.

slide130

Risk factors

  • Chronic lung disease
    • Independent risk factor for A. fumigatus sternal wound infection after open-heart surgery
    • A. fumigatus grew at the same time from the bronchial washing of one patient
    • Colonised patients may be at increased risk.

Richet HM, et al. Am J Epidemiol 1992; 135: 48-58.

slide132

Ophthalmological surgery

  • Usually keratitis; rarely endophthalmitis

Tabbara KF, et al. Ophthalmology 1998; 105: 522-6.

Sridhar MS, et al. Am J Ophthalmol 2000; 129: 802-4.

slide133
Penetrating keratoplasty

Radial keratotomy

Excimer laser photorefractive keratectomy

Laser-assisted in situ keratomileusis

Pterygium excision

Cataract surgery

Scleral buckling procedures

Hydroxyapatite orbital implant surgery

Sutureless surgery

Trabeculectomy

Ophthalmological surgery

  • Usually keratitis; rarely endophthalmitis
  • Many different procedures
slide134

Ophthalmological surgery

  • Sampling at the site of infection: best chance for obtaining a positive culture
slide135

Ophthalmological surgery

  • Sampling at the site of infection: best chance for obtaining a positive culture
  • Source of infection:
    • Hospital construction
slide136

Ophthalmological surgery

  • Sampling at the site of infection: best chance for obtaining a positive culture
  • Source of infection:
    • Hospital construction
    • Contaminated irrigating fluids used during surgery
slide137

Ophthalmological surgery

  • Sampling at the site of infection: best chance for obtaining a positive culture
  • Source of infection:
    • Hospital construction
    • Contaminated irrigating fluids used during surgery
    • Many occurred after non-surgical corneal trauma.
slide139

Surgical dental procedure

  • Connection between endodontic treatment and non-invasive sinus aspergillosis
slide140

Surgical dental procedure

  • Connection between endodontic treatment and non-invasive sinus aspergillosis
  • Obturating pastes containing zinc oxid within the maxillary antrum
slide141

Surgical dental procedure

  • Connection between endodontic treatment and non-invasive sinus aspergillosis
  • Obturating pastes containing zinc oxid within the maxillary antrum
  • Surgical treatment
    • Removal of all material
    • Promote aeration
    • Antifungals only if invasion.
slide143

Treatment

  • Optimal therapy: not specifically studied
slide144

Treatment

  • Optimal therapy: not specifically studied
  • Excision of the infected tissue
slide145

Treatment

  • Optimal therapy: not specifically studied
  • Excision of the infected tissue
  • Placement of a new prosthesis in a non-infected field
slide146

Treatment

  • Optimal therapy: not specifically studied
  • Excision of the infected tissue
  • Placement of a new prosthesis in a non-infected field
  • Systemic antifungal agents
slide147

Treatment

  • Optimal therapy: not specifically studied
  • Excision of the infected tissue
  • Placement of a new prosthesis in a non-infected field
  • Systemic antifungal agents
  • Longer term oral therapy
slide148

Treatment

  • Optimal therapy: not specifically studied
  • Excision of the infected tissue
  • Placement of a new prosthesis in a non-infected field
  • Systemic antifungal agents
  • Longer term oral therapy
  • Duration: unknown.
slide150

Main sources of infection

  • Contaminated grafts
slide151

Main sources of infection

  • Contaminated grafts
  • Contaminated sutures
slide152

Main sources of infection

  • Contaminated grafts
  • Contaminated sutures
  • Intra-operative dispersion of spores.
slide153

Linking the infection with the surgical room

  • “Pigeon excreta in the immediate vicinity of the ventilator intake port were found to harbour large numbers of Aspergillus spores”

Gage AA, et al. Arch Surg 1970; 101: 384-87.

slide154

Linking the infection with the surgical room

  • “Air conditioner cooling coils and pigeon droppings on the ledges outside the suite were found to harbour Aspergillus spores in large amounts”.

Mehta G. J Hosp Infect 1990; 15: 245-53.

slide156

Infection acquired in the ICU

  • Multiple abdominal visceral infection by A. fumigatus occurred afterlaparostomy

Carlson GL, et al. J Infect 1996; 33: 119-21.

slide157

Infection acquired in the ICU

  • Multiple abdominal visceral infection by A. fumigatus occurred afterlaparostomy

Dark patches on the liver invading liver capsule

Carlson GL, et al. J Infect 1996; 33: 119-21.

slide158

Infection acquired in the ICU

  • Multiple abdominal visceral infection by A. fumigatus occurred after laparostomy
  • Sampling of air from the ICU yielded one isolate that matched the patient's isolates.

Carlson GL, et al. J Infect 1996; 33: 119-21.

slide159

Fomites as a reservoir

  • Grilles of heat exchanger used to maintain extracorporeal blood at the proper temperature.

Diaz-Guerra TM, et al. J Clin Microbiol 2000; 38: 2419-22.

slide160

RAPD patterns

  • Three primers

(A, B, C)

  • 1, 2:
    • Environmental
  • 3:
    • Aortic prosthesis

Diaz-Guerra TM, et al. J Clin Microbiol 2000; 38: 2419-22.

slide161

Prevention

  • Tap water: not on surgical wounds
slide162

Prevention

  • Tap water: not on surgical wounds
  • Conventional ventilation and filters onlyremove airborne particles  5 m
slide163

Prevention

  • Tap water: not on surgical wounds
  • Conventional ventilation and filters only remove airborne particles  5 m
  • Laminar airflow systems and HEPA filtration
slide164

Prevention

  • Tap water: not on surgical wounds
  • Conventional ventilation and filters only remove airborne particles  5 m
  • Laminar airflow systems and HEPA filtration
    • Lack of data revealing survival benefit
    • Costs
slide165

Prevention

  • Tap water: not on surgical wounds
  • Conventional ventilation and filters only remove airborne particles  5 m
  • Laminar airflow systems and HEPA filtration
    • Lack of data revealing survival benefit
    • Costs
    • Lack of consensus about the level of airborne conidia at which the risk can be numerically defined.
slide166

HEPA filtration is importantbut maybe not enough

HEPA

filtration

HEPA

filtration

Offices, meeting rooms, lounges, utilities, storage rooms

Heinemann S, et al. J Hosp Infect 2004; 57: 149-55.

slide167

Outbreak of A. flavuswound infection

Heavily

contaminated areas

Heinemann S, et al. J Hosp Infect 2004; 57: 149-55.

slide168

Outbreak of A. flavuswound infection

Water leakage

Heinemann S, et al. J Hosp Infect 2004; 57: 149-55.

slide169

RAPD results

Heinemann S, et al. J Hosp Infect 2004; 57: 149-55.

slide170

Penicillium in the OR

  • Investigating Aspergillus infections

Fox BC. Am J Infect Control 1990; 18: 300-6.

slide171

Penicillium in the OR

  • Investigating Aspergillus infections
  • Heavy contamination by Penicillium in the heating, ventilation, and air conditioning (HVAC) system of the OR.

Fox BC. Am J Infect Control 1990; 18: 300-6.

slide172

Penicillium in the OR

Terminal units lined with fibreglass served as a substrate for fungal growth.

Fox BC. Am J Infect Control 1990; 18: 300-6.

slide173

Deteriorated ventilation systems

Lutz G, et al. Clin Infect Dis 2003; 37: 786-93.

slide175

Conclusion

  • Underappreciated problem
slide176

Conclusion

  • Underappreciated problem
  • Mortality: high in non-cutaneous infections
slide177

Conclusion

  • Underappreciated problem
  • Mortality: high in non-cutaneous infections
  • Different organs and surgical procedures
slide178

Conclusion

  • Underappreciated problem
  • Mortality: high in non-cutaneous infections
  • Different organs and surgical procedures
  • Usually indolent
slide179

Conclusion

  • Underappreciated problem
  • Mortality: high in non-cutaneous infections
  • Different organs and surgical procedures
  • Usually indolent
  • Combined aggressive medical and surgical therapy.
slide180

Conclusion

  • Prevention:
    • Special care with the ventilation system in the surgical room
slide181

Conclusion

  • Prevention:
    • Special care with the ventilation system in the surgical room
    • Proper storage and disinfection of surgical material.
slide182

Acknowledgments

  • David W. Denning
slide183

Acknowledgments

  • David W. Denning
  • Fungal Research Trust
slide184

Acknowledgments

  • David W. Denning
  • Fungal Research Trust
  • CAPES

alessandro.pasqualotto@manchester.ac.uk