Consensus guidelines for implementation of quality processes to prevent invasive fungal disease and enhanced surveillance measures during hospital building works, 2014

Healthcare-associated fungal outbreaks impose a substantial economic burden on the health system and typically result in high patient morbidity and mortality, particularly in the immunocompromised host. As the population at risk of invasive fungal infection continues to grow due to the increased burden of cancer and related factors, the need for hospitals to employ preventative measures has become increasingly important. These guidelines outline the standard quality processes hospitals need to accommodate into everyday practice and at times of healthcare-associated outbreak, including the role of antifungal stewardship programmes and best practice environmental sampling. Specific recommendations are also provided to help guide the planning and implementation of quality processes and enhanced surveillance before, during and after high-risk activities, such as hospital building works. Areas in which information is still lacking and further research is required are also highlighted.

Invasive infections due to filamentous fungi other than Aspergillus: epidemiology and determinants of mortality

The epidemiology of invasive fungal disease (IFD) due to filamentous fungi other than Aspergillus may be changing. We analysed clinical, microbiological and outcome data in Australian patients to determine the predisposing factors and identify determinants of mortality. Proven and probable non-Aspergillus mould infections (defined according to modified European Organization for Research and Treatment of Cancer/Mycoses Study Group criteria) from 2004 to 2012 were evaluated in a multicentre study. Variables associated with infection and mortality were determined. Of 162 episodes of non-Aspergillus IFD, 145 (89.5%) were proven infections and 17 (10.5%) were probable infections. The pathogens included 29 fungal species/species complexes; mucormycetes (45.7%) and Scedosporium species (33.3%) were most common. The commonest comorbidities were haematological malignancies (HMs) (46.3%) diabetes mellitus (23.5%), and chronic pulmonary disease (16%); antecedent trauma was present in 21% of cases. Twenty-five (15.4%) patients had no immunocompromised status or comorbidity, and were more likely to have acquired infection following major trauma (p <0.01); 61 (37.7%) of cases affected patients without HMs or transplantation. Antifungal therapy was administered to 93.2% of patients (median 68 days, interquartile range 19-275), and adjunctive surgery was performed in 58.6%. The all-cause 90-day mortality was 44.4%; HMs and intensive-care admission were the strongest predictors of death (both p <0.001). Survival varied by fungal group, with the risk of death being significantly lower in patients with dematiaceous mould infections than in patients with other non-Aspergillus mould infections. Non-Aspergillus IFD affected diverse patient groups, including non-immunocompromised hosts and those outside traditional risk groups; therefore, definitions of IFD in these patients are required. Given the high mortality, increased recognition of infections and accurate identification of the causative agent are required.

Identification and possible disease mechanisms of an under-recognized fungus, Aureobasidium pullulans

Background: Investigations into the occurrence and health effects of yeast-like fungi in the outdoor air in the US have been limited. We sought to identify a respirable-sized fungus common in the Pasadena air, locate a major source for the emissions and investigate its relevance to allergic disease. Methods: Yeast-like fungi sampled from the environment were isolated, microscopically examined and sequenced. Pasadena allergy patients were skin tested with commercially available fungal extracts. Patient serum was immunoanalyzed for specific IgE reactivity. Nearby vegetation was analyzed in a controlled emission chamber to find a major source for the aerosols. Results: Hyaline unicellular conidia comprised up to 90% (41,250 m^-3 of air) of total fungal counts and generally peaked at night and during periods of rainfall and ensuing winds throughout the fall and winter. Flowers were determined to be a major source of the emissions. The cellular and colonial morphology of isolates were consistent with Aureobasidium species. The sequence of the D1/D2 region of the 26S ribosomal subunit of isolates from flowers showed identity to two strains of Aureohasidium pullulans (black yeast). Seventeen percent (16/94) of atopic individuals had positive skin testing with A. pullulans extract. Patient sera gE identified several high molecular weight allergens in Aureobasidium extracts. Conclusions: Respirable-sized conidia of A. pullulans are emitted from flowers and form high concentrations in the air. They are associated with immediate reactivity on skin tests, bind to patient sera IgE, and might be relevant in allergic upper and lower airway diseases.

High adult mortality in disease-challenged frog populations increases vulnerability to drought

Pathogen emergence can drive major changes in host population demography, with implications for population dynamics and sensitivity to environmental fluctuations. The amphibian disease chytridiomycosis, caused by infection with the fungal pathogen Batrachochytrium dendrobatidis (Bd), is implicated in the severe decline of over 200 amphibian species. In species that have declined but not become extinct, Bd persists and can cause substantial ongoing mortality. High rates of mortality associated with Bd may drive major changes in host demography, but this process is poorly understood. Here, we compared population age structure of Bd-infected populations, Bd-free populations, and museum specimens collected prior to Bd emergence for the endangered Australian frog, Litoria verreauxii alpina (alpine tree frog). We then used population simulations to investigate how pathogen-associated demographic shifts affect the ability of populations to persist in stochastic environments. We found that Bd-infected populations have a severely truncated age structure associated with very high rates of annual adult mortality. Near-complete annual adult turnover in Bd-infected populations means that individuals breed once, compared with Bd-free populations where adults may breed across multiple years. Our simulations showed that truncated age structure erodes the capacity of populations to withstand periodic recruitment failure; a common challenge for species reproducing in uncertain environments. We document previously undescribed demographic shifts associated with a globally emerging pathogen and demonstrate how these shifts alter host ecology. Truncation of age structure associated with Bd effectively reduces host niche width, and can help explain the contraction of L. v. alpina to perennial waterbodies where the risk of drought-induced recruitment failure is low. Reduced capacity to tolerate other sources of mortality may explain variation in decline severity among other chytridiomycosis-challenged species and highlights the potential to mitigate disease impacts through minimising other sources of mortality.

Reservoir-host amplification of disease impact in an endangered amphibian

Emerging wildlife pathogens are an increasing threat to biodiversity. One of the most serious wildlife diseases is chytridiomycosis, caused by the fungal pathogen, Batrachochytrium dendrobatidis (Bd), which has been documented in over 500 amphibian species. Amphibians vary greatly in their susceptibility to Bd, with some species tolerating infection, while others experience rapid mortality. Reservoir hosts - species that carry infection while maintaining high abundance, but are rarely killed by disease - can increase extinction risk in highly susceptible, sympatric species. However, whether reservoir hosts amplify Bd in declining amphibian species has not been examined. We combine a laboratory study with field surveys, disease sampling, and statistical modeling to investigate the role of reservoir hosts in chytridiomycosis dynamics and species decline in an amphibian community in south-eastern Australia. We show that the non-declining common eastern froglet (Crinia signifera) is a reservoir host for Bd, with laboratory animals carrying intense infection burdens over 12 weeks and the majority of wild sampled individuals carrying intense infections. We find that the presence of C. signifera is strongly associated with Bd prevalence in the sympatric, IUCN red-listed northern corroboree frog (Pseudophryne pengilleyi). Consistent with disease amplification by a reservoir host, we find that P. pengilleyi has declined from areas with high C. signifera abundance. Our results suggest that when reservoir hosts are present, population declines can continue long after the initial emergence of Bd, highlighting an urgent need to assess extinction risk in remnant populations of other declined amphibian species. Reintroductions and in situ management strategies must focus on identifying reservoir hosts and minimizing exposure of threatened species.