Lecture on Prevention of Fungal Infections by Dr. Gamini Kumarasinghe during the 6th International Infection Control Conference 2006

1. PREVENTION OF FUNGAL INFECTIONS Gamini Kumarasinghe Division of Microbiology National University Hospital, Singapore

2. Fungi range in size C. albicans chlamydospores Polyporus sulphureus Amanita muscaria Mycelia inside potato Black bread mold Mycelia on various foods

5. The usual reservoir - not an infected human or animal - a site in nature where the fungus is growing as a saprophyte Prevention Of Fungal Infections Chung & Bennett, 1992

6. Because human mycoses are poorly communicable from person to person, mycoses are often endemic but rarely epidemic. Prevention Of Fungal Infections Chung & Bennett, 1992

7. Prevention Of Fungal Infections mopping the floor e.g. diving boards & floor mats periodically with a fungicidal solution

8. ISOLATION PRECAUTIONS ?

10. INFECTION IN THE HOSPITAL Immuno-compromised patients

11. Aspergillosis Infection In The Hospital

16. Anteroom Patient’s Room Bed Exhaust PPV : 12 ACH LAF : 400 ACH Positive Pressure Ventilation Room Adapted from HPAC, 2000

17. Aspergillosis Keeping patients in such special rooms - considerable cost - nursing care, medical attention - emotional stress on the patient Infection In The Hospital

19. HEPA filters Haematological malignancies - protective for highly IC patients - effective at controlling outbreaks due to Aspergillus conidia (Hahn et al., 2002) Protective Isolation

20. HEPA filters Bone marrow transplant recipients - tenfold greater incidence than other IC patients - risk could be eliminated by using HEPA with LAF (Sheretz et al., 1987) Protective Isolation

21. Portable HEPA filters ? Protective Isolation

22. Portable HEPA filters - costly preventive strategy of questionable value 1 - under field conditions portable units not recommended 2 1. Mantadakis & Samonis, 2006 2. Engelhart et al., 2003 Protective Isolation

23. Nosocomial infections: other moulds Fusarium, Trichosporon spp., dematiaceous moulds, Zygomycetes etc may affect immunocompromised patients (Walter EA, 1995)

25. IC individuals risk infections by more than 270 species Fungal Infections Perfect JR, 2005 Good housekeeping

26. Candidiasis Infection In The Hospital

27. Candidiasis The usual reservoir is the patient's own body Infection In The Hospital

28. Candidiasis Patients with severe and prolonged neutropenia Prone to develop disseminated candidiasis from numerous small ulcers caused by Candida species in the stomach, oesophagus, and intestine Infection In The Hospital

29. Prevention of candidiasis Despite massive oral doses of nystatin , to reduce Candida in stools prevention of disseminated candidiasis has not been convincingly demonstrated Infection In The Hospital

33. INFECTION IN THE LABORATORY

38. PRECAUTIONS WITH INFECTED LABORATORY ANIMALS

40. Environmental control

42. Outbreaks of infections after construction work in hospitals (Bodey & Vartivarian, 1989) Environmental control Aspergillus spp. & other molds

47. One year old study in a major tertiary care hospital About 200 bone marrow and organ transplants / yr Dept of Environmental and Occupational Health Science, University of Illinois at Chicago Fungi in the environment Curtis et al, 2005

53. Routine measures – not the ideal solution Fungal Infection Prevention

56. Antimicrobials administered to patients at high risk of developing the disease, who are not infected and not manifesting symptomatic disease. Prophylaxis Goodman et al., 1992

58. Toxicity & cost are major shortcomings of such therapy Hence, “preemptive” approach Emperic therapy Maertens clin inf dis 2005 Nov 1

59. Preemptive Therapy

60. The administration of antimicrobials to patients already infected , but who do not yet manifest symptomatic disease in whom there are markers of pathogen invasion Synonymous with secondary prophylaxis or preventive therapy Preemptive Therapy Singh N., 2001

63. Microbiologic markers Non culture based assays

67. Candida markers Mannan is a major component of the Candida cell wall Platelia Ag/Ab; Bio-Rad Lab 93% specificity & 80% sensitivity (Sendid et al., 1999 & 2002, Year et al., 2001)

68. PROPHYLAXIS

74. Pneumocystis jirovecii Children acute lymphoblastic leukemia allogeneic BMT SCT recipients - are known high-risk groups that should be offered prophylaxis. Momin & Chandrasekar, 1995: Link et al, 1993

75. New antifungal agents

77. Summary and Conclusions

78. Summary of major recommendation for prevention of invasive fungal infection (Sullivan et al, 2001) Handwashing to prevent spread of exogenous Candida species Fungal surveillance cultures are not indicated in asymptomatic patients Topical antifungal agents are not recommended for prevention of invasive fungal infection Fluconazole (400 mg/day) is recommended to prevent invasive yeast Patients are to avoid hospital construction or renovation areas Alll Dll Dll All Alll Type of Prevention Rating