Concurrent surveillance of blood culture isolates in a 1000-bed tertiary care hospital over a 7-year period from 1986 to 1993 identified 102 episodes of nosocomial fungaemia, representing 6.6% of all episodes of nosocomial bloodstream infections and 0.49/1000 admissions. No significant change in the frequency, rate, source or microbial aetiology of nosocomial fungaemia occurred over the 7-year period. Candida albicans accounted for 74%, followed by Candida (Torulopsis) glabrata (8%), C. parapsilosis (7%), C. tropicalis (3%), C. lusitaniae (2%), C. krusei, Malassezia furfur Saccharomyces cerevisiae, Hansenula anomala and Cryptococcus albidus (one each). 'Primary' fungaemia, usually attributed to intravascular catheters, was considered to be the source in 65% of cases, with 64% of these patients receiving total parenteral nutrition (TPN). Other important sources of infection included the urinary tract (11%), the gastrointestinal tract (8%) and the respiratory tract (7%). Sixty-four % of patients were in one of the hospital's seven intensive care units (ICUs) when their infection developed, the neonatal ICU and adult medical/surgical ICU each accounting for 21%. Only 7% of cases were associated with neutropenia and another 14% with malignancy or immunosuppression. Death occurred within 7 days of diagnosis of fungaemia in 23 cases. In eight instances, fungaemia was considered the main cause of death. We conclude that in our hospital nosocomial fungaemia is largely caused by C. albicans, occurring in association with intravascular catheter use and TPN in ICU patients. Most cases are not associated with recognized immune defence defects. Fungaemia is associated with a high short-term mortality rate.
Mucorales are environmental fungi, often found in soil and decaying matter. 1,2 Most infections are sporadic-and community-acquired, although there are reported cases of hospital acquisition. Healthcareassociated outbreaks have been linked to adhesive bandages, ostomy bags, wooden tongue depressors, environmental contamination, and invasive medical devices. 3 During a 6-month period, three cases of mucormycosis were identified in recipients of solid organ transplantation. The cases occurred within 3 weeks of the transplant surgery suggesting hospital acquisition. Following this cluster of cases, Infection Prevention and Control (IPC) conducted an outbreak investigation, which included the use of genome sequencing. Herein, we report these cases and demonstrate how genome sequencing can complement traditional IPC outbreak investigations of mucormycosis. Case patients were defined as solid organ transplant recipients from July to December 2017 who had phenotypically identified Rhizomucor species from clinical samples ≥14 days after hospital admission. 3-5 No case patients were discharged from hospital between the time of transplant to diagnosis of mucormycosis. Case-patient 1 is a 70-year-old male who underwent double lung transplantation for idiopathic pulmonary fibrosis. Bronchoscopies post-transplant day (PTD) 1 and 6 were negative for fungal growth. A bronchoalveolar lavage specimen from PTD 11 grew Rhizomucor species in fungal culture. He was started on intravenous liposomal and inhaled amphotericin B on PTD 14. Repeat bronchoscopy samples collected on PTD 26 showed fungal elements but fungal cultures were negative. On PTD 47, treatment was changed to isavuconazole because of kidney injury. His hypoxia improved, and he was repatriated to a community hospital for convalescence and ultimate discharge. Fourteen months after his transplant, he has not had a relapse. Case-patient 2 is a 64-year-old male who underwent double lung transplantation 5 months after case-patient 1 for chronic obstructive pulmonary disease. Following an episode of acute hypoxia, a bronchoscopy was done on PTD 13. Samples collected grew a fungus microscopically identified as Rhizomucor species, although this result was not noted immediately by clinicians. On PTD 33, the patient underwent gastroscopy for an upper gastrointestinal bleed which revealed a gastric ulcer. Biopsies from a repeat gastroscopy showed fungal elements consistent with mucormycosis. Repeat bronchoscopies on PTD 41 and 49 again isolated a fungus microscopically identified as Rhizomucor species. Cranial imaging, to assess altered AbstractWe report three cases of hospital-acquired mucormycosis in heart and lung transplant patients over a 6-month period. Traditional epidemiological investigation tools were used to look for a common link between patients to explain the outbreak.
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