Fungal pathogens in cancer patients

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Fungal pathogens in cancer patients

• Opportunistic yeasts
• Candida spp. C. albicans, non-albicans Candida
  spp.
• Cryptococcus C. neoformans
• Other Yeasts Trichosporon species,
  Blastoschizomyces species
• Opportunistic molds (hyalohyphomycetes)
• Aspergillus spp. A. fumigatus, A. terreus, A.
  flavus, A. niger, others
• Fusarium spp. F. solani, F. oxysporum, and
  others
• Zygomycetes Rhizopus spp., Mucor, Absidia
• Dematiaceous molds (phaeohyphomycetes)
• Pseudallescheria boydii,
  Bipolaris, Scedosporum,
• Alternaria and other
  rare pathogens
• Endemic dimorphic molds
• Histoplasma capsulatum,
  Coccidioides immitis
• Blastomyces
  dermatitidis, Penicillium marneffei

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Nosocomial ICU Bloodstream Infections in US
(1995-2002)
Wisplinghoff et al CID 200439309
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Primary Prophylaxis
Colonized (Pre-emptive)
Therapy Induction Maintenance
Symptoms (Empiric)
Secondary Prophylaxis
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Empirical antifungal therapy in the ICU?

• In the febrile non-neutropenic patient?
• - Early treatment is theoretically beneficial
• IDSA guidelines 2000
• - Appropriate use has not been defined
• Here is the Albrecht Rule
• - Days in critical care (days x number of
  antibiotics)
• number of risk factors (GI, TPN, steroids,
  lines) gt 25
• especially if colonized gt think (and treat)
  fungus
• Apropos colonization
• - Anywhere works for me
• - The more sites with fungus the higher the risk
  
• (Pittet Ann Surg 94)

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Fungus Food

• Anything organic (contains the element carbon)
• Cardboard
• Wallpaper glue
• Soap and body oil
• Carpet fibers

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aspergillus from hospital water sites
Warris et al J Hosp Inf 2001 47 143
Anaissee et al Clin Infect Dis 2002 43 780
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Health Effects of Mold

• Molds produce three major health effects
• infection
• allergic reactions
• toxicity
• Many physicians do not believe that the levels of
  mold found in indoor environments can adversely
  effect human health (dose versus response)

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Guidelines

• Healthcare Infection Control Practices Advisory
  Committee (HICPAC)
• Guideline for Preventing Healthcare-Associated
  Pneumonia 2004 CDC
• Guideline for Environmental Infection Control in
  Health-Care Facilities, 2003 CDC
• Air Handling Systems
• Airborne Infectious Isolation (AII) Rooms
• Protective Environments (PE)
• Construction, Renovation, Remediation, Repair
  Demolition

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Fungi Control

• You can clean without disinfecting
• You can NOT disinfect without cleaning

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Fungicides/Fungistats

• Sodium Hypochlorite (Bleach)
• Phenols
• Quaternary Ammonium Compounds
• Acids
• Copper-8-Quinolinate

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Mold Abatement

• Address the source of the water incursion before
  beginning clean up of mold
• Porous surfaces very difficult to clean
• Removal often the only option for ceiling tiles,
  drywall, carpeting
• Soap and water is usually sufficient, except for
  sewage incursion, which requires disinfection

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Large Scale Abatement

• Abatement of large areas of mold damage requires
  many of the same work practices used for asbestos
  (area isolation, wet cleaning methods,
  directional air flow with HEPA filtration)

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Infection Control IssuesDuring Construction

• Relocate high-risk patients, issue
  high-efficiency masks
• Decrease high-risk admissions
• Close patient room and unit doors
• Damp-mop or HEPA-vacuum vicinity
• Check air filters regularly
• Monitor air quality

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Post-Construction Phase

• Thoroughly clean renovated patient areas
• Pay special attention to air ducts
• Obtain cultures, particle counts
• Verify integrity of ventilation system

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Final Points to Remember

• Understand risks for construction projects
• Educate contractor, workers in infection control
• Monitor compliance to IC procedures

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Antifungal Therapy

• Fungi are

• Eukaryotes
• Usually haploid organisms

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Bug
Drug
Higher inocculum More heteroresistance ?
Drug/target ratio Delayed diagnosis
Infarction Drug delivery ? Penetration Bioavailabi
lity
Steroids Neutropenia Congenital
Immunedeficiency HIV/AIDS Transplant
Host