A Guide to Investigating Suspected Outbreaks of Mucormycosis in Healthcare

Hartnett, Kathleen P.; Jackson, Brendan R; Perkins, Kiran M.; Glowicz, Janet; Kerins, Janna L.; Black, Stéphanie; Lockhart, Shawn R.; Christensen, Bryan; Beer, Karlyn D.

doi:10.3390/jof5030069

Cited by 63 publications

(80 citation statements)

References 115 publications

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“…In a publication from India, 75 cases of mucormycosis were reported during an eighteen-month period, of which 9% were nosocomial [ 20 ]. Healthcare-associated mucormycosis has been attributed to various exposures in the hospital environment [ 75 ]: The use of non-sterile products is the most commonly suspected cause of infection [ 76 ]. Bandages, adhesives, nitroglycerin patches [ 77 ], contaminated linen [ 78 ], wooden tongue depressors, ostomy bags [ 79 ] and probiotics have all been implicated.…”

Section: Epidemiologymentioning

confidence: 99%

Epidemiology and Diagnosis of Mucormycosis: An Update

Skiada

Pavleas

Drogari‐Apiranthitou

2020

JoF

494

508

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Mucormycosis is an angioinvasive fungal infection, due to fungi of the order Mucorales. Its incidence cannot be measured exactly, since there are few population-based studies, but multiple studies have shown that it is increasing. The prevalence of mucormycosis in India is about 80 times the prevalence in developed countries, being approximately 0.14 cases per 1000 population. Diabetes mellitus is the main underlying disease globally, especially in low and middle-income countries. In developed countries the most common underlying diseases are hematological malignancies and transplantation. Τhe epidemiology of mucormycosis is evolving as new immunomodulating agents are used in the treatment of cancer and autoimmune diseases, and as the modern diagnostic tools lead to the identification of previously uncommon genera/species such as Apophysomyces or Saksenaea complex. In addition, new risk factors are reported from Asia, including post-pulmonary tuberculosis and chronic kidney disease. New emerging species include Rhizopus homothallicus, Thamnostylum lucknowense, Mucor irregularis and Saksenaea erythrospora. Diagnosis of mucormycosis remains challenging. Clinical approach to diagnosis has a low sensitivity and specificity, it helps however in raising suspicion and prompting the initiation of laboratory testing. Histopathology, direct examination and culture remain essential tools, although the molecular methods are improving. The internal transcribed spacer (ITS) region is the most widely sequenced DNA region for fungi and it is recommended as a first-line method for species identification of Mucorales. New molecular platforms are being investigated and new fungal genetic targets are being explored. Molecular-based methods have gained acceptance for confirmation of the infection when applied on tissues. Methods on the detection of Mucorales DNA in blood have shown promising results for earlier and rapid diagnosis and could be used as screening tests in high-risk patients, but have to be validated in clinical studies. More, much needed, rapid methods that do not require invasive procedures, such as serology-based point-of-care, or metabolomics-based breath tests, are being developed and hopefully will be evaluated in the near future.

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Section: Epidemiologymentioning

confidence: 99%

Epidemiology and Diagnosis of Mucormycosis: An Update

Skiada

Pavleas

Drogari‐Apiranthitou

2020

JoF

494

508

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“…As shown here, the end result within a hospital or community is a dynamic ecology of new, transient and more entrenched lineages. The implications of our findings for epidemiological investigations are that a failure to demonstrate definitive associations between clinical and environment strains does not preclude hospital-acquired mucormycosis or an outbreak, assessments of hospital-acquired mucormycosis should use WGS on several isolates from an individual patient and a large number of environmental isolates, and investigations are best conducted at the time of active cases, which may be difficult due to delayed recognition of case clusters [20, 25].…”

Section: Discussionmentioning

confidence: 99%

“…Clade 5 comprised 12 isolates identifed as R. delemar by ITS and D1/D2 sequencing, including an isolate from index SOT patient P1 (month 0), six linen-associated isolates (months [16][17][18][19][20], and five regional environmental isolates (months 14-18). Isolate L35-GL20, identified by ITS and D1/D2 as R. arrhizus, also clustered within this clade.…”

Section: Phylogenomic Relatedness Of Mucorales Isolatesmentioning

confidence: 99%

“…Healthcare-associated mucormycosis has been ascribed to on-campus construction, as well as contaminated hospital linen, adhesive wrappings, bandages, wooden tongue depressors, drugs, food, ostomy bags and air handling systems [1,[4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19]. The distinction between healthcareassociated and community-acquired mucormycosis often is unclear because the incubation period is unknown, long-term colonization can occur among at-risk patients, and nosocomial case clusters may be caused by multiple species of Mucorales [20].…”

Section: Introductionmentioning

confidence: 99%

“…Previous WGS-based epidemiological studies were limited further by a failure to recover Mucorales during environmental surveillance for comparison with clinical isolates [24, 25]. The genomic variability of Mucorales within hospitals and surrounding communities is unknown [20].…”

Section: Introductionmentioning

confidence: 99%

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Genetic diversity of clinical and environmental Mucorales isolates obtained from an investigation of mucormycosis cases among solid organ transplant recipients

et al. 2020

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Mucormycoses are invasive infections by Rhizopus species and other Mucorales. Over 10 months, four solid organ transplant (SOT) recipients at our centre developed mucormycosis due to Rhizopus microsporus (n=2), R. arrhizus (n=1) or Lichtheimia corymbifera (n=1), at a median 31.5 days (range: 13–34) post-admission. We performed whole genome sequencing (WGS) on 72 Mucorales isolates (45 R. arrhizus, 19 R. delemar, six R. microsporus, two Lichtheimia species) from these patients, from five patients with community-acquired mucormycosis, and from hospital and regional environments. Isolates were compared by core protein phylogeny and global genomic features, including genome size, guanine–cytosine percentages, shared protein families and paralogue expansions. Patient isolates fell into six core phylogenetic lineages (clades). Phylogenetic and genomic similarities of R. microsporus isolates recovered 7 months apart from two SOT recipients in adjoining hospitals suggested a potential common source exposure. However, isolates from other patients and environmental sites had unique genomes. Many isolates that were indistinguishable by core phylogeny were distinct by one or more global genomic comparisons. Certain clades were recovered throughout the study period, whereas others were found at particular time points. In conclusion, mucormycosis cases could not be genetically linked to a definitive environmental source. Comprehensive genomic analyses eliminated false associations between Mucorales isolates that would have been assigned using core phylogenetic or less extensive genomic comparisons. The genomic diversity of Mucorales mandates that multiple isolates from individual patients and environmental sites undergo WGS during epidemiological investigations. However, exhaustive surveillance of fungal populations in a hospital and surrounding community is probably infeasible.

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Re-Emerging Systemic Mucormycosis Associated With COVID-19 Infection in Africa

Akinyosoye

Akinduti

2022

Bioenergy and Biochemical Processing Technologies

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A Guide to Investigating Suspected Outbreaks of Mucormycosis in Healthcare

Cited by 63 publications

References 115 publications

Epidemiology and Diagnosis of Mucormycosis: An Update

Epidemiology and Diagnosis of Mucormycosis: An Update

Genetic diversity of clinical and environmental Mucorales isolates obtained from an investigation of mucormycosis cases among solid organ transplant recipients

Re-Emerging Systemic Mucormycosis Associated With COVID-19 Infection in Africa

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