Postoperative aspergillosis Alessandro C. Pasqualotto School of Medicine, The University of Manchester Wythenshawe Hospital, UK

Case report Male, 70 year-oldMale, 70 year-old Elective aortic valve replacementElective aortic valve replacement

Case report Male, 70 year-oldMale, 70 year-old Elective aortic valve replacementElective aortic valve replacement 4 months: fatigue and physical endurance4 months: fatigue and physical endurance

Case report Male, 70 year-oldMale, 70 year-old Elective aortic valve replacementElective aortic valve replacement 4 months: fatigue and physical endurance4 months: fatigue and physical endurance 7 months: profuse diarrhoea7 months: profuse diarrhoea

Case report Male, 70 year-oldMale, 70 year-old Elective aortic valve replacementElective aortic valve replacement 4 months: fatigue and physical endurance4 months: fatigue and physical endurance 7 months: profuse diarrhoea7 months: profuse diarrhoea One week later: chills + feverOne week later: chills + fever 19,000 x 10 6 leukocytes.19,000 x 10 6 leukocytes.

Case report TEE: large aortic vegetationTEE: large aortic vegetation

Case report TEE: large aortic vegetationTEE: large aortic vegetation Blood cultures: negativeBlood cultures: negative

Case report TEE: large aortic vegetationTEE: large aortic vegetation Blood cultures: negativeBlood cultures: negative Working diagnosis: viridans strep endocarditisWorking diagnosis: viridans strep endocarditis

Case report TEE: large aortic vegetationTEE: large aortic vegetation Blood cultures: negativeBlood cultures: negative Working diagnosis: viridans strep endocarditisWorking diagnosis: viridans strep endocarditis Discharged on ceftriaxone and metronidazoleDischarged on ceftriaxone and metronidazole

Case report TEE: large aortic vegetationTEE: large aortic vegetation Blood cultures: negativeBlood cultures: negative Working diagnosis: viridans strep endocarditisWorking diagnosis: viridans strep endocarditis Discharged on ceftriaxone and metronidazoleDischarged on ceftriaxone and metronidazole Readmitted for fever and CHFReadmitted for fever and CHF

Case report TEE: large aortic vegetationTEE: large aortic vegetation Blood cultures: negativeBlood cultures: negative Working diagnosis: viridans strep endocarditisWorking diagnosis: viridans strep endocarditis Discharged on ceftriaxone and metronidazoleDischarged on ceftriaxone and metronidazole Readmitted for fever and CHFReadmitted for fever and CHF Vancomycin and doxycycline were added.Vancomycin and doxycycline were added.

Case report After 2 days: hemiparesis and aphasiaAfter 2 days: hemiparesis and aphasia

Case report After 2 days: hemiparesis and aphasiaAfter 2 days: hemiparesis and aphasia He died three days laterHe died three days later

Case report After 2 days: hemiparesis and aphasiaAfter 2 days: hemiparesis and aphasia He died three days laterHe died three days later Autopsy:Autopsy: –Massive cerebral haemorrhage –Embolus containing Aspergillus in the right middle cerebral artery

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

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

Is that correct?

Would someone have suspected aspergillosis?

Aspergillosis Aspergillus are ubiquitousAspergillus are ubiquitous –Soil, water and decaying vegetation

Aspergillosis Aspergillus are ubiquitousAspergillus are ubiquitous –Soil, water and decaying vegetation Primarily acquired by inhalationPrimarily acquired by inhalation

Aspergillosis Aspergillus are ubiquitousAspergillus are ubiquitous –Soil, water and decaying vegetation Primarily acquired by inhalationPrimarily acquired by inhalation Nosocomial aspergillosis typically affects immunocompromised patients.Nosocomial aspergillosis typically affects immunocompromised patients.

That is not all the story …

The spectrum of aspergillosis Frequency of aspergillosis

The spectrum of aspergillosis Immune system Frequency of aspergillosis

The spectrum of aspergillosis Disfunction Frequency of aspergillosis Immune system

The spectrum of aspergillosis Acute IA Frequency of aspergillosis Disfunction Immune system

The spectrum of aspergillosis Acute IA Subacute IA Frequency of aspergillosis Disfunction Immune system

The spectrum of aspergillosis Acute IA Subacute IA. Tracheobronchitis Fungus ball Chronic cavitary Chronic fibrosing Frequency of aspergillosis Disfunction Immune system Normal

The spectrum of aspergillosis Acute IA Subacute IA ABPA Allergic sinusitis. Frequency of aspergillosis Disfunction Immune system NormalHyper immune Tracheobronchitis Fungus ball Chronic cavitary Chronic fibrosing

What about postoperative aspergillosis?

Review of the world literature Medline, LILACS and EMBASEMedline, LILACS and EMBASE

References were reviewedReferences were reviewed Review of the world literature

Medline, LILACS and EMBASEMedline, LILACS and EMBASE References were reviewedReferences were reviewed Conference abstracts ( abstracts ( Review of the world literature

Medline, LILACS and EMBASEMedline, LILACS and EMBASE References were reviewedReferences were reviewed Conference abstracts ( abstracts ( Only cases of proven or probable aspergillosis were reviewed.Only cases of proven or probable aspergillosis were reviewed. Review of the world literature

Not included:Not included: –Primary cutaneous aspergillosis Review of the world literature

Not included:Not included: –Primary cutaneous aspergillosis Review of the world literature Neonate Andresen J, et al. Acta Paediatr 2005; 94:

Not included:Not included: –Primary cutaneous aspergillosis Review of the world literature Neonate Diabetes mellitus

Not included:Not included: –Primary cutaneous aspergillosis Review of the world literature Neonate Diabetes mellitus Burn patient

Not included:Not included: –Infections associated with intravascular devices Review of the world literature

Not included:Not included: –Infections associated with intravascular devices Review of the world literature Neutropenia

Not included:Not included: –Infections associated with intravascular devices Review of the world literature Neutropenia HIV

Literature review More than 500 cases were includedMore than 500 cases were included

Literature review –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 More than 500 cases were includedMore than 500 cases were included

Endocarditis and aortitis 124 cases124 cases

Endocarditis and aortitis 124 cases40 other cases124 cases40 other cases

Endocarditis and aortitis 124 cases124 cases Male gender: 69.9%Male gender: 69.9%

Endocarditis and aortitis 124 cases124 cases Male gender: 69.9%Male gender: 69.9% Median age: 43.5 years-old (0.8 to 71)Median age: 43.5 years-old (0.8 to 71)

Endocarditis and aortitis 124 cases124 cases Male gender: 69.9%Male gender: 69.9% Median age: 43.5 years-old (0.8 to 71)Median age: 43.5 years-old (0.8 to 71) Main valves:Main valves: –Aortic: involved in 60.5% –Mitral: 30.6%

Endocarditis and aortitis 124 cases124 cases Male gender: 69.9%Male gender: 69.9% Median age: 43.5 years-old (0.8 to 71)Median age: 43.5 years-old (0.8 to 71) Main valves:Main valves: –Aortic: involved in 60.5% –Mitral: 30.6% Median 2.7 months after surgery ( 12).Median 2.7 months after surgery ( 12).

Key features Absence of immunosuppressionAbsence of immunosuppression

Key features Absence of immunosuppressionAbsence of immunosuppression No bronchopulmonary aspergillosisNo bronchopulmonary aspergillosis

Key features Absence of immunosuppressionAbsence of immunosuppression No bronchopulmonary aspergillosisNo bronchopulmonary aspergillosis Postoperative course consistent with culture-negative endocarditisPostoperative course consistent with culture-negative endocarditis

Key features Absence of immunosuppressionAbsence of immunosuppression No bronchopulmonary aspergillosisNo bronchopulmonary aspergillosis Postoperative course consistent with culture-negative endocarditisPostoperative course consistent with culture-negative endocarditis Propensity to late embolisation.Propensity to late embolisation.

Aspergillus species A. fumigatus: 58.7%A. fumigatus: 58.7%

Aspergillus species A. fumigatus: 58.7%A. fumigatus: 58.7% A. terreus: 12.5%A. terreus: 12.5%

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

Large destructive lesion on the mitral valve

Hosking MC, et al. Ann Thorac Surg 1995; 59: Large vegetations

Diagnosis Antemortem diagnosis: 43.5%Antemortem diagnosis: 43.5%

Diagnosis –Vegetation, valve/graft examination: 23.4%

Diagnosis Antemortem diagnosis: 43.5%Antemortem diagnosis: 43.5% –Vegetation, valve/graft examination: 23.4% –Embolic material: 16.9%

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

Diagnosis Antemortem diagnosis: 43.5%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%.

Diagnosis Other diagnostic methods?Other diagnostic methods?

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

Diagnosis Other diagnostic methods?Other diagnostic methods? Negative galactomannan (ELISA) Pemán J, et al. 2 nd TIMM, Berlin P-048.

Mortality Overall mortality: 92.7%Overall mortality: 92.7%

Mortality Antemortem diagnosis: mortality 83.0%Antemortem diagnosis: mortality 83.0%(p<0.0001)

Mortality Overall mortality: 92.7%Overall mortality: 92.7% Antemortem diagnosis: mortality 83.0%Antemortem diagnosis: mortality 83.0%(p<0.0001) Surgical treatment: 80.9%.Surgical treatment: 80.9%.

Aortic graft infection

Aspergillus graft infection n=22n=22

Aspergillus graft infection n=22n=22 Almost all cases: immunocompetent malesAlmost all cases: immunocompetent males

Aspergillus graft infection n=22n=22 Almost all cases: immunocompetent malesAlmost all cases: immunocompetent males Median 8 months after surgeryMedian 8 months after surgery

Aspergillus graft infection n=22n=22 Almost all cases: immunocompetent malesAlmost all cases: immunocompetent males Median 8 months after surgeryMedian 8 months after surgery –Candida graft infections: usually < 6 weeks

Aspergillus graft infection n=22n=22 Almost all cases: immunocompetent malesAlmost all cases: immunocompetent males Median 8 months after surgeryMedian 8 months after surgery –Candida graft infections: usually < 6 weeks Similar to S. epidermidis infectionSimilar to S. epidermidis infection

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

Brandt SJ, et al. Am J Med 1985; 79:

Definitive diagnostic procedures Culture of the excised aortic graftCulture of the excised aortic graft

Culture of peripheral embolusCulture of peripheral embolus Definitive diagnostic procedures

Culture of the excised aortic graftCulture of the excised aortic graft Culture of peripheral embolusCulture of peripheral embolus Biopsy of the contiguously affected vertebral disk.Biopsy of the contiguously affected vertebral disk. Definitive diagnostic procedures

Treatment Effective treatment: removal of the graftEffective treatment: removal of the graft

Treatment Systemic antifungal therapySystemic antifungal therapy

Treatment Effective treatment: removal of the graftEffective treatment: removal of the graft Systemic antifungal therapySystemic antifungal therapy Extra-anatomic bypass through a clean field.Extra-anatomic bypass through a clean field.

Neurosurgical infection

Case report Female, 16 year-oldFemale, 16 year-old Elective neurosurgery for Chiari I malformationElective neurosurgery for Chiari I malformation

Case report Female, 16 year-oldFemale, 16 year-old Elective neurosurgery for Chiari I malformationElective neurosurgery for Chiari I malformation Long course of dexamethasoneLong course of dexamethasone

Case report Female, 16 year-oldFemale, 16 year-old Elective neurosurgery for Chiari I malformationElective neurosurgery for Chiari I malformation Long course of dexamethasoneLong course of dexamethasone Clinical deteriorationClinical deterioration –Vancomycin and cefotaxime –Dexamethasone dose was increased.

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

Is that a contaminant?

Case report Symptoms persistedSymptoms persisted

Case report Symptoms persistedSymptoms persisted Wound exploration: sutures had dehiscedWound exploration: sutures had dehisced

Case report Symptoms persistedSymptoms persisted Wound exploration: sutures had dehiscedWound exploration: sutures had dehisced Cultures again revealed A. fumigatusCultures again revealed A. fumigatus Amphotericin B was started (day 28)Amphotericin B was started (day 28)

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

Case report A. fumigatus in the surgical specimensA. fumigatus in the surgical specimens

Case report A. fumigatus in the surgical specimensA. fumigatus in the surgical specimens She died 2 months after the 1 st surgeryShe died 2 months after the 1 st surgery

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

Case report A. fumigatus in the surgical specimensA. fumigatus in the surgical specimens She died 2 months after the 1 st surgeryShe died 2 months after the 1 st surgery Autopsy: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.

Aspergillosis after neurosurgery n=25n=25

Aspergillosis after neurosurgery n=25n=25 Male sex: 44.0%Male sex: 44.0%

n=25n=25 Male sex: 44.0%Male sex: 44.0% Steroids: 52.0%Steroids: 52.0% Aspergillosis after neurosurgery

n=25n=25 Male sex: 44.0%Male sex: 44.0% Steroids: 52.0%Steroids: 52.0% All proven cases: A. fumigatus.All proven cases: A. fumigatus. Aspergillosis after neurosurgery

Median 3 months after surgery ( 12)Median 3 months after surgery ( 12) Aspergillosis after neurosurgery

Median 3 months after surgery ( 12)Median 3 months after surgery ( 12) Different presentationsDifferent presentations –Meningitis –CNS abscess –Mycotic aneurisms –Infarction. Aspergillosis after neurosurgery

Antemortem diagnosis: 64.0%Antemortem diagnosis: 64.0% Aspergillosis after neurosurgery

Antemortem diagnosis: 64.0%Antemortem diagnosis: 64.0% –Abscess examination: 36.0% Aspergillosis after neurosurgery

Antemortem diagnosis: 64.0%Antemortem diagnosis: 64.0% –Abscess examination: 36.0% –Culture of CSF: 20.0% Aspergillosis after neurosurgery

Antemortem diagnosis: 64.0%Antemortem diagnosis: 64.0% –Abscess examination: 36.0% –Culture of CSF: 20.0% Mortality: 68.0%.Mortality: 68.0%. Aspergillosis after neurosurgery

Trans-sphenoidal surgery Endo T, et al. Surg Neurol 2001; 56:

Wound infection

Definitions Skin or subcutaneous tissue of the incisionSkin or subcutaneous tissue of the incision

Definitions When both superficial and deep incision sites: classified as deep surgical site infectionWhen both superficial and deep incision sites: classified as deep surgical site infection

Definitions Skin or subcutaneous tissue of the incisionSkin or subcutaneous tissue of the incision When both superficial and deep incision sites: classified as deep surgical site infectionWhen both superficial and deep incision sites: classified as deep surgical site infection Similar to CDCs criteria for SSI.Similar to CDCs criteria for SSI.

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

Definitions Topographic relation between the surgery and the infectionTopographic relation between the surgery and the infection

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

The first case reported Frank L, Alton OM. JAMA 1933; 100:

The first case reported Female, 40 year-oldFemale, 40 year-old Operated on for an abdominal tumourOperated on for an abdominal tumour Frank L, Alton OM. JAMA 1933; 100:

The first case reported Female, 40 year-oldFemale, 40 year-old Operated on for an abdominal tumourOperated on for an abdominal tumour After 16 days: ulcer under the dressingAfter 16 days: ulcer under the dressing No systemic manifestationsNo systemic manifestations Frank L, Alton OM. JAMA 1933; 100:

The first case reported Female, 40 year-oldFemale, 40 year-old Operated on for an abdominal tumourOperated on for an abdominal tumour After 16 days: ulcer under the dressingAfter 16 days: ulcer under the dressing No systemic manifestationsNo systemic manifestations A. niger grew in the surgical dressings covered with a dark powder.A. niger grew in the surgical dressings covered with a dark powder. Frank L, Alton OM. JAMA 1933; 100:

Particularities Median 17 days after surgery (<7 to 180)Median 17 days after surgery (<7 to 180)

Particularities Many patients were immunosuppressedMany patients were immunosuppressed

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

Risk of dissemination Aggressive combined medical therapy and debridement is required for all patients.Aggressive combined medical therapy and debridement is required for all patients.

Outbreaks Outbreak of wound aspergillosisOutbreak of wound aspergillosis –Contamination during hospital construction of the outside packages of dressing supplies Bryce EA, et al. Infect Control Hosp Epidemiol 1996; 17:

Outbreaks Outbreak of wound aspergillosisOutbreak of wound aspergillosis –Contamination during hospital construction of the outside packages of dressing supplies Outbreaks of cutaneous aspergillosisOutbreaks of cutaneous aspergillosis –Wound dressing and tape should be cultured Bryce EA, et al. Infect Control Hosp Epidemiol 1996; 17:

Outbreaks Outbreak of wound aspergillosisOutbreak of wound aspergillosis –Contamination during hospital construction of the outside packages of dressing supplies Outbreaks of cutaneous aspergillosisOutbreaks of cutaneous aspergillosis –Wound dressing and tape should be cultured A. flavus sternal wound infection coinciding with hospital renovation activities.A. flavus sternal wound infection coinciding with hospital renovation activities. Bryce EA, et al. Infect Control Hosp Epidemiol 1996; 17:

Risk factors Chronic lung diseaseChronic lung disease –Independent risk factor for A. fumigatus sternal wound infection after open-heart surgery Richet HM, et al. Am J Epidemiol 1992; 135:

Risk factors Chronic lung diseaseChronic 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:

Risk factors Chronic lung diseaseChronic 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:

Ophthalmological surgery

Usually keratitis; rarely endophthalmitisUsually keratitis; rarely endophthalmitis Tabbara KF, et al. Ophthalmology 1998; 105: Sridhar MS, et al. Am J Ophthalmol 2000; 129:

Ophthalmological surgery Usually keratitis; rarely endophthalmitisUsually keratitis; rarely endophthalmitis Many different proceduresMany different procedures –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 Sampling at the site of infection: best chance for obtaining a positive cultureSampling at the site of infection: best chance for obtaining a positive culture

Ophthalmological surgery Sampling at the site of infection: best chance for obtaining a positive cultureSampling at the site of infection: best chance for obtaining a positive culture Source of infection:Source of infection: –Hospital construction

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

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

Surgical dental procedure

Connection between endodontic treatment and non-invasive sinus aspergillosisConnection between endodontic treatment and non-invasive sinus aspergillosis

Surgical dental procedure Connection between endodontic treatment and non-invasive sinus aspergillosisConnection between endodontic treatment and non-invasive sinus aspergillosis Obturating pastes containing zinc oxid within the maxillary antrumObturating pastes containing zinc oxid within the maxillary antrum

Surgical dental procedure Connection between endodontic treatment and non-invasive sinus aspergillosisConnection between endodontic treatment and non-invasive sinus aspergillosis Obturating pastes containing zinc oxid within the maxillary antrumObturating pastes containing zinc oxid within the maxillary antrum Surgical treatmentSurgical treatment –Removal of all material –Promote aeration –Antifungals only if invasion.

Treatment

Treatment Optimal therapy: not specifically studiedOptimal therapy: not specifically studied

Treatment Excision of the infected tissueExcision of the infected tissue

Treatment Optimal therapy: not specifically studiedOptimal therapy: not specifically studied Excision of the infected tissueExcision of the infected tissue Placement of a new prosthesis in a non- infected fieldPlacement of a new prosthesis in a non- infected field

Treatment Optimal therapy: not specifically studiedOptimal therapy: not specifically studied Excision of the infected tissueExcision of the infected tissue Placement of a new prosthesis in a non- infected fieldPlacement of a new prosthesis in a non- infected field Systemic antifungal agentsSystemic antifungal agents

Treatment Optimal therapy: not specifically studiedOptimal therapy: not specifically studied Excision of the infected tissueExcision of the infected tissue Placement of a new prosthesis in a non- infected fieldPlacement of a new prosthesis in a non- infected field Systemic antifungal agentsSystemic antifungal agents Longer term oral therapyLonger term oral therapy

Treatment Optimal therapy: not specifically studiedOptimal therapy: not specifically studied Excision of the infected tissueExcision of the infected tissue Placement of a new prosthesis in a non- infected fieldPlacement of a new prosthesis in a non- infected field Systemic antifungal agentsSystemic antifungal agents Longer term oral therapyLonger term oral therapy Duration: unknown.Duration: unknown.

Prevention

Main sources of infection Contaminated graftsContaminated grafts

Main sources of infection Contaminated graftsContaminated grafts Contaminated suturesContaminated sutures

Main sources of infection Contaminated graftsContaminated grafts Contaminated suturesContaminated sutures Intra-operative dispersion of spores.Intra-operative dispersion of spores.

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 sporesPigeon 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:

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.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:

Infection acquired in the ICU Carlson GL, et al. J Infect 1996; 33: Carlson GL, et al. J Infect 1996; 33: Multiple abdominal visceral infection by A. fumigatus occurred after laparostomyMultiple abdominal visceral infection by A. fumigatus occurred after laparostomy

Infection acquired in the ICU Carlson GL, et al. J Infect 1996; 33: Carlson GL, et al. J Infect 1996; 33: Dark patches on the liver invading liver capsule Multiple abdominal visceral infection by A. fumigatus occurred after laparostomyMultiple abdominal visceral infection by A. fumigatus occurred after laparostomy

Infection acquired in the ICU Multiple abdominal visceral infection by A. fumigatus occurred after laparostomyMultiple abdominal visceral infection by A. fumigatus occurred after laparostomy Sampling of air from the ICU yielded one isolate that matched the patient's isolates.Sampling of air from the ICU yielded one isolate that matched the patient's isolates. Carlson GL, et al. J Infect 1996; 33:

Grilles of heat exchanger used to maintain extracorporeal blood at the proper temperature.Grilles of heat exchanger used to maintain extracorporeal blood at the proper temperature. Diaz-Guerra TM, et al. J Clin Microbiol 2000; 38: Fomites as a reservoir

Diaz-Guerra TM, et al. J Clin Microbiol 2000; 38: RAPD patterns Three primersThree primers (A, B, C) 1, 2:1, 2: –Environmental 3:3: –Aortic prosthesis

Prevention Tap water: not on surgical woundsTap water: not on surgical wounds

Prevention Conventional ventilation and filters only remove airborne particles 5 mConventional ventilation and filters only remove airborne particles 5 m

Prevention Tap water: not on surgical woundsTap water: not on surgical wounds Conventional ventilation and filters only remove airborne particles 5 mConventional ventilation and filters only remove airborne particles 5 m Laminar airflow systems and HEPA filtrationLaminar airflow systems and HEPA filtration

Prevention Tap water: not on surgical woundsTap water: not on surgical wounds Conventional ventilation and filters only remove airborne particles 5 mConventional ventilation and filters only remove airborne particles 5 m Laminar airflow systems and HEPA filtrationLaminar airflow systems and HEPA filtration –Lack of data revealing survival benefit –Costs

Prevention Tap water: not on surgical woundsTap water: not on surgical wounds Conventional ventilation and filters only remove airborne particles 5 mConventional ventilation and filters only remove airborne particles 5 m Laminar airflow systems and HEPA filtrationLaminar 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.

Heinemann S, et al. J Hosp Infect 2004; 57: HEPAfiltration Offices, meeting rooms, lounges, utilities, storage rooms HEPA filtration is important but maybe not enough HEPAfiltration

Heinemann S, et al. J Hosp Infect 2004; 57: Outbreak of A. flavus wound infection Heavily contaminated areas

Heinemann S, et al. J Hosp Infect 2004; 57: Outbreak of A. flavus wound infection Water leakage

Heinemann S, et al. J Hosp Infect 2004; 57: RAPD results

Investigating Aspergillus infections Fox BC. Am J Infect Control 1990; 18: 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: Penicillium in the OR

Fox BC. Am J Infect Control 1990; 18: Terminal units lined with fibreglass served as a substrate for fungal growth. Penicillium in the OR

Lutz G, et al. Clin Infect Dis 2003; 37: Deteriorated ventilation systems

Conclusion

Conclusion Underappreciated problemUnderappreciated problem

Conclusion Mortality: high in non-cutaneous infectionsMortality: high in non-cutaneous infections

Conclusion Underappreciated problemUnderappreciated problem Mortality: high in non-cutaneous infectionsMortality: high in non-cutaneous infections Different organs and surgical proceduresDifferent organs and surgical procedures

Conclusion Underappreciated problemUnderappreciated problem Mortality: high in non-cutaneous infectionsMortality: high in non-cutaneous infections Different organs and surgical proceduresDifferent organs and surgical procedures Usually indolentUsually indolent

Conclusion Underappreciated problemUnderappreciated problem Mortality: high in non-cutaneous infectionsMortality: high in non-cutaneous infections Different organs and surgical proceduresDifferent organs and surgical procedures Usually indolentUsually indolent Combined aggressive medical and surgical therapy.Combined aggressive medical and surgical therapy.

Conclusion Prevention:Prevention: –Special care with the ventilation system in the surgical room

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

Acknowledgments David W. DenningDavid W. Denning

Acknowledgments Fungal Research TrustFungal Research Trust

Acknowledgments David W. DenningDavid W. Denning Fungal Research TrustFungal Research Trust