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Airborne Fungal Diseases
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Immune Compromised Hosts
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Skin Infection with Fungi
Fungal Contamination of Buildings
Fungi in Hospitals
Allergy to Fungi
Fungi in Food
Aspergillus

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Fatal Brain Infection
Dr G's 2 slide culture
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Reflections on an Illness

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Stephen Gislason MD

Hospital Infections with Fungi

Fungi are found everywhere. Hospitals are not the clean, germ free places we would like them to be. Instead, hospitals concentrate pathogenic organisms including fungi. Hospital also concentrate patients whose immune defences are compromised, even shut down so that infections of all kinds are very common.

The two most prevalent fungal infections in hospitals are caused by Candida and Aspergillus species. The prevention of fungal infections in hospitals should a priority but in practice few preventive measures are deployed. Diagnosis and treatment remain difficult at best.

Pappas stated: "Invasive fungal infections are an increasingly important consideration in the medical care of critically ill patients and in patients with immunosuppression. New methods may increase the rate and accuracy of the diagnosis of invasive fungal infections, and the use of scoring systems that consider the risk factors for the development of invasive fungal infections may allow earlier therapy,  a critical component of the successful treatment of these serious infections.

Husain et al studied fungal infections in 53 liver and heart transplant recipients: Invasive mycelial infections were due to Aspergillus species in 69.8% of patients, to non-Aspergillus hyalohyphomycetes in 9.4%, to phaeohyphomycetes in 9.4%, to zygomycetes in 5.7%, and to other causes in 5.7%. Overall mortality at 90 days was 54.7%. The associated mortality rate was 100% for zygomycosis, 80% for non-Aspergillus hyalohyphomycosis, 54% for aspergillosis, and 20% for phaeohyphomycosis. Thus, non-Aspergillus molds have emerged as significant pathogens in organ transplant recipients. These molds are more likely to be associated with disseminated infections and to be associated with poorer outcomes than is aspergillosis. Clin Infect Dis.  2003; 37(2):221-9 (ISSN: 1537-6591)

A concern is the emergence of more resistant fungi; better selection of at risk patients for antifungal prophylaxis will reduce indiscriminate drug use and reduce the rate of fungal evolution.

Candida albicans is the most common  fungal pathogen among immune-compromised, hospitalized patients, accounting for roughly 50-60% of all bloodstream fungal isolates. Candida species are an important cause of infection in intensive care units increased by 207% from 1979 to 2000. Risk factors include  chemotherapy, organ transplants, abdominal surgery, central vascular lines, often used in ICU patients; the use of multiple or broad-spectrum antibiotics;  total parenteral nutrition (TPN). The incidence of candida infection increases the longer a patient stays in hospital with peak incidence of infection around day 10.

Waknine reported that makers of tumor necrosis factor (TNF)-blocking agents were ordered to strengthen warnings regarding the risk for histoplasmosis and other invasive fungal infections by the US Food and Drug Administration. Since the initial approval of the 4 TNF blockers, the prescribing information for these drugs has included information about the risk of serious infections, including fungal infections; however physician are  not recognizing cases of histoplasmosis and other invasive fungal infections, leading to delays in treatment.

The US FDA has received 240 reports of histoplasmosis in patients receiving infliximab (Remicade); 207 cases from etanercept (Enbrel); and adalimumab (Humira) 16 cases. 1 case occurred during treatment with certolizumab pegol (Cimziac), approved in 2008. Missed diagnoses in 21 patients led to treatment delays and 12 deaths.  Fatal cases of coccidioidomycosis and blastomycosis have also been reported. Healthcare professionals are advised to closely monitor patients for signs and symptoms of  fungal infection during and after treatment with anti-TNF drugs. Patients who develop fever, malaise, weight loss, sweats, cough, dyspnea, pulmonary infiltrates on X-ray, or serious systemic illness should undergo a "complete diagnostic workup."

The FDA advised that a high index of suspicion should be maintained for invasive fungal infections in symptomatic patients. If possible, the decision to initiate empiric antifungal therapy should be made in conjunction with an infectious diseases specialist.  An infectious disease consultation is also recommended when determining the duration of antifungal therapy and whether anti-TNF therapy should be resumed on recovery, particularly for patients who reside in regions of endemic mycoses.  TNF blockers are immunosuppressive agents approved to treat  immune system diseases, including juvenile idiopathic arthritis, rheumatoid arthritis, psoriatic arthritis, plaque psoriasis, Crohn's disease, and ankylosing spondylitis.

Yael Waknine. Patient Deaths Spark Stronger Warnings for TNF Blockers. Medscape Medical News 2008. Accessed online September 4, 2008. In the US, adverse events related to use of anti-TNF agents should be reported to the FDA's MedWatch reporting program by telephone at 1-800-FDA-1088, by fax at 1-800-FDA-0178, online at http://www.fda.gov/medwatch, or by mail to 5600 Fishers Lane, Rockville, MD 20852-9787.

Pappas PG, Rex JH, Sobel JD, et al. Guidelines for treatment of candidiasis. Clin Infect Dis. 2004;38:161-189.

Segal BH, Walsh TJ. Current approaches to diagnosis and treatment of invasive aspergillosis. Am J Respir Crit Care Med. 2006;173:707-717

Cornely OA, Maertens J, Winston DJ, et al. Posaconazole vs. fluconazole or itraconazole prophylaxis in patients with neutropenia. N Engl J Med. 2007;356:348-359

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