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.

Functional status after bloodstream infection : the survivors' trajectory

There is very little information about the quality of survival for patients after bacterial and fungal bloodstream infections. This study aimed to describe the functional status and level of activities of daily living for a group of survivors of these infections. A prospective exploratory design was used to track adults for 6 months after onset of infection. Survivors were assessed for reduced or full health status. Telephone interviews, using the London Handicap Scale and the Sickness Impact Profile, provided self-assessed functional status for those able to participate; 165 adults were tracked. Before infection, only 25% of adults had an active malignancy and one-tenth required a high level of assistance with activities of daily living. Six months after infection, half of survivors had reduced health and many had not returned to their normal functional activity level. There was considerable continued reduced health in survivors, demonstrating that not only do bloodstream infections result in high short-term mortality but also in considerable longer term morbidity and profound alteration in functional health status for many survivors.

The putative role of viruses, bacteria, and chronic fungal biotoxin exposure in the genesis of intractable fatigue accompanied by cognitive and physical disability

Patients who present with severe intractable apparently idiopathic fatigue accompanied by profound physical and or cognitive disability present a significant therapeutic challenge. The effect of psychological counseling is limited, with significant but very slight improvements in psychometric measures of fatigue and disability but no improvement on scientific measures of physical impairment compared to controls. Similarly, exercise regimes either produce significant, but practically unimportant, benefit or provoke symptom exacerbation. Many such patients are afforded the exclusionary, non-specific diagnosis of chronic fatigue syndrome if rudimentary testing fails to discover the cause of their symptoms. More sophisticated investigations often reveal the presence of a range of pathogens capable of establishing life-long infections with sophisticated immune evasion strategies, including Parvoviruses, HHV6, variants of Epstein-Barr, Cytomegalovirus, Mycoplasma, and Borrelia burgdorferi. Other patients have a history of chronic fungal or other biotoxin exposure. Herein, we explain the epigenetic factors that may render such individuals susceptible to the chronic pathology induced by such agents, how such agents induce pathology, and, indeed, how such pathology can persist and even amplify even when infections have cleared or when biotoxin exposure has ceased. The presence of active, reactivated, or even latent Herpes virus could be a potential source of intractable fatigue accompanied by profound physical and or cognitive disability in some patients, and the same may be true of persistent Parvovirus B12 and mycoplasma infection. A history of chronic mold exposure is a feasible explanation for such symptoms, as is the presence of B. burgdorferi. The complex tropism, life cycles, genetic variability, and low titer of many of these pathogens makes their detection in blood a challenge. Examination of lymphoid tissue or CSF in such circumstances may be warranted.

Associations between outdoor fungal spores and childhood and adolescent asthma hospitalisations.

BACKGROUND: Childhood asthma is a significant public health problem and severe exacerbations can result in diminished quality of life and hospitalisation. OBJECTIVE: To examine the contribution of outdoor fungi to childhood and adolescent asthma hospitalisations. METHODS: The Melbourne Air Pollen Children and Adolescent (MAPCAH) study is a case-crossover study of 644 children and adolescents (aged 2-17 years) hospitalised for asthma. MAPCAH collected individual data on human rhinovirus (HRV) infection and sensitisation to Alternaria and Cladosporium; and daily counts of ambient concentrations of fungal spores, pollen and air pollutants. Conditional logistic regression models were used to assess associations with increases in spore counts while controlling for potential confounding and testing interactions. RESULTS: Exposure to Alternaria (aOR=1.07, 95%CI 1.03-1.11), Leptosphaeria (aOR=1.05, 95%CI 1.02-1.07), Coprinus (aOR=1.04, 95%CI 1.01-1.07), Drechslera (aOR=1.03, 95%CI1.00-1.05) and total spores (aOR=1.05, 95%CI 1.01-1.09) were significantly associated with child asthma hospitalisations independent of HRV infection. There were significant lagged effects up to 3-days with Alternaria, Leptosphaeria, Cladosporium, Sporormiella, Coprinus, and Drechslera. Some of these associations were significantly greater in participants with Cladosporium sensitisation. CONCLUSION: Exposures to several outdoor fungal spore taxa, including some not reported in previous research, are associated with the risk of child and adolescent asthma hospitalisation, particularly in individuals sensitised to Cladosporium. We need further studies to examine cross-reactivity causing asthma exacerbations. Identifying sensitisation to multiple fungal allergens in asthmatic children could support the design and implementation of more effective strategies to prevent asthma exacerbations.