postoperative aspergillosis alessandro c. pasqualotto school of medicine, the university of...

Postoperative Postoperative aspergillosisaspergillosis

Alessandro C. PasqualottoAlessandro C. Pasqualotto

School of Medicine, The University of ManchesterSchool of Medicine, The University of ManchesterWythenshawe Hospital, UKWythenshawe Hospital, UK

http://www.manchester.ac.uk/

Case reportCase report

• Male, 70 year-oldMale, 70 year-old

• Elective aortic valve replacementElective aortic valve replacement

www.aspergillus.man.ac.uk/secure/casehistories/case048.htm





• 4 months:4 months: fatigue and fatigue and physical endurance physical endurance






• 4 months: fatigue and 4 months: fatigue and physical endurance physical endurance

• 7 months:7 months: profuse diarrhoea profuse diarrhoea



Case reportCase report• Male, 70 year-oldMale, 70 year-old


• 4 months: fatigue and 4 months: fatigue and physical endurance physical endurance

• 7 months: profuse diarrhoea7 months: profuse diarrhoea

• One week later:One week later: chills + fever chills + fever

• 19,000 x 1019,000 x 1066 leukocytes. leukocytes.




• TEE:TEE: large aortic vegetation large aortic vegetation




• TEE: large aortic vegetationTEE: large aortic vegetation

• Blood cultures:Blood cultures: negative negative





• Blood cultures: negativeBlood cultures: negative

• Working diagnosis:Working diagnosis: viridans strep endocarditis viridans strep endocarditis






• Working diagnosis: viridans strep endocarditisWorking diagnosis: viridans strep endocarditis

• DischargedDischarged on ceftriaxone and metronidazole on ceftriaxone and metronidazole



Case reportCase report• TEE: large aortic vegetationTEE: large aortic vegetation



• Discharged on ceftriaxone and metronidazoleDischarged on ceftriaxone and metronidazole

• ReadmittedReadmitted for fever and CHF for fever and CHF



Case reportCase report• TEE: large aortic vegetationTEE: large aortic vegetation



• Discharged on ceftriaxone and metronidazoleDischarged on ceftriaxone and metronidazole

• Readmitted for fever and CHFReadmitted for fever and CHF

• Vancomycin and doxycyclineVancomycin and doxycycline were added. were added.




• After 2 days:After 2 days: hemiparesis and aphasia hemiparesis and aphasia




• After 2 days: hemiparesis and aphasiaAfter 2 days: hemiparesis and aphasia

• He He dieddied three days later three days later



Case reportCase report• After 2 days: hemiparesis and aphasiaAfter 2 days: hemiparesis and aphasia

• He died three days laterHe died three days later

• Autopsy:Autopsy:

– Massive cerebral haemorrhageMassive cerebral haemorrhage

– Embolus containing Embolus containing AspergillusAspergillus in the right middle cerebral arteryin the right middle cerebral artery







– Embolus containing Embolus containing Aspergillus Aspergillus in the right middle cerebral arteryin the right middle cerebral artery

– Endocarditis lesion:Endocarditis lesion: multiple hyphae multiple hyphae







– Embolus containing Embolus containing Aspergillus Aspergillus in the right middle cerebral arteryin the right middle cerebral artery

– Endocarditis lesion: multiple hyphaeEndocarditis lesion: multiple hyphae

– No other site of infection was found.No other site of infection was found.



Is that correct?Is that correct?


Would someone have Would someone have suspected aspergillosis?suspected aspergillosis?


AspergillosisAspergillosis

• Aspergillus Aspergillus are are ubiquitousubiquitous

– Soil, water and decaying vegetationSoil, water and decaying vegetation



• Aspergillus Aspergillus are ubiquitous are ubiquitous


• Primarily acquired by Primarily acquired by inhalationinhalation



• Aspergillus Aspergillus are ubiquitous are ubiquitous


• Primarily acquired by inhalationPrimarily acquired by inhalation• Nosocomial aspergillosis typically affects Nosocomial aspergillosis typically affects

immunocompromised patients.immunocompromised patients.


That is not all the story …That is not all the story …


The spectrum of aspergillosisThe spectrum of aspergillosisF

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The spectrum of aspergillosisThe spectrum of aspergillosis

Immune system

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Disfunction

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Immune system www.aspergillus.man.ac.uk


Acute IA

Fre

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Disfunction



Acute IA

Subacute IA

Fre

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Disfunction



Acute IA

Subacute IA

.

TracheobronchitisTracheobronchitisFungus ballFungus ballChronic cavitaryChronic cavitaryChronic fibrosingChronic fibrosing

Fre

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Disfunction

Immune system

Normal



Acute IA

Subacute IA

ABPAAllergic sinusitis

.

Fre

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Disfunction

Immune system

Normal Hyper immune

TracheobronchitisTracheobronchitisFungus ballFungus ballChronic cavitaryChronic cavitaryChronic fibrosingChronic fibrosing


What about postoperative What about postoperative aspergillosis?aspergillosis?


Review of the world literatureReview of the world literature

• Medline, LILACS and EMBASEMedline, LILACS and EMBASE



• References References were reviewedwere reviewed




• References were reviewedReferences were reviewed

• Conference abstracts Conference abstracts (www.aspergillus.man.ac.uk)(www.aspergillus.man.ac.uk)




• References were reviewedReferences were reviewed

• Conference abstracts Conference abstracts (www.aspergillus.man.ac.uk)(www.aspergillus.man.ac.uk)

• Only cases of Only cases of proven or probableproven or probable aspergillosis were reviewed. aspergillosis were reviewed.



• Not included:Not included:

– Primary cutaneous aspergillosis






Neonate

Andresen J, et al. Acta Paediatr 2005; 94: 761-2.





Neonate

Diabetes mellitus





Neonate

Diabetes mellitus Burn patient




– Infections associated with intravascular devices






Neutropenia





Neutropenia HIV


Literature reviewLiterature review

• More than More than 500 cases500 cases were included were included

Literature reviewLiterature review

– Heart surgery: 188Heart surgery: 188

– Dental surgery: > 100Dental surgery: > 100

– Ophthalmologic Ophthalmologic

surgery: > 90surgery: > 90

– Wound infections: 22Wound infections: 22

– Neurosurgery: 25Neurosurgery: 25

– Vascular prosthetic Vascular prosthetic

surgery: 22surgery: 22

– Orthopaedic surgery: 42Orthopaedic surgery: 42

– Bronchial infections: 30Bronchial infections: 30

– Abdominal surgery: 10Abdominal surgery: 10

– Mediastinitis: 11Mediastinitis: 11

– Breast surgery: 5Breast surgery: 5

– Pleural aspergillosis: 1Pleural aspergillosis: 1

• More than More than 500 cases500 cases were included were included

Endocarditis and aortitisEndocarditis and aortitis

• 124 cases124 cases



• 124 cases124 cases 40 other cases40 other cases




• Male gender:Male gender: 69.9% 69.9%




• Male gender: 69.9%Male gender: 69.9%

• Median age:Median age: 43.5 years-old (0.8 to 71) 43.5 years-old (0.8 to 71)





• Median age: 43.5 years-old (0.8 to 71)Median age: 43.5 years-old (0.8 to 71)

• Main valves:Main valves:

– Aortic: involved in 60.5%Aortic: involved in 60.5%

– Mitral: 30.6%Mitral: 30.6%





• Median age: 43.5 years-old (0.8 to 71)Median age: 43.5 years-old (0.8 to 71)

• Main valves:Main valves:

– Aortic: involved in 60.5%Aortic: involved in 60.5%

– Mitral: 30.6%Mitral: 30.6%

• Median Median 2.7 months after surgery2.7 months after surgery (<1 to > 12). (<1 to > 12).


Key featuresKey features

• Absence of immunosuppressionAbsence of immunosuppression




• No bronchopulmonary aspergillosisNo bronchopulmonary aspergillosis





• Postoperative course consistent with Postoperative course consistent with culture-negative endocarditisculture-negative endocarditis





• Postoperative course consistent with culture-negative endocarditisPostoperative course consistent with culture-negative endocarditis

• Propensity to Propensity to late embolisation.late embolisation.


AspergillusAspergillus species species

• A. fumigatusA. fumigatus: : 58.7%58.7%


AspergillusAspergillus species species

• A. fumigatusA. fumigatus: 58.7%: 58.7%

• A. terreusA. terreus:: 12.5% 12.5%


AspergillusAspergillus species species• A. fumigatusA. fumigatus: 58.7%: 58.7%

• A. terreusA. terreus: 12.5%: 12.5%

• A. flavusA. flavus:: 11.2% 11.2%

• A. nigerA. niger:: 11.2% 11.2%

• A. glaucusA. glaucus: 2.5%: 2.5%

• A. clavatusA. clavatus: 1.2%: 1.2%

• A. ustusA. ustus: 1.2%: 1.2%

• A. sydowiA. sydowi: 1.2%: 1.2%

• AA. spp:. spp: 20.0% 20.0%


Large destructive lesion on Large destructive lesion on the mitral valve the mitral valve


Hosking MC, et al. Ann Thorac Surg 1995; 59: 1015-7.

Large vegetationsLarge vegetations

DiagnosisDiagnosis

• Antemortem diagnosis:Antemortem diagnosis: 43.5% 43.5%


DiagnosisDiagnosis


– Vegetation, valve/graft examination:Vegetation, valve/graft examination: 23.4% 23.4%


DiagnosisDiagnosis


– Vegetation, valve/graft examination: 23.4%Vegetation, valve/graft examination: 23.4%

– Embolic material:Embolic material: 16.9% 16.9%


DiagnosisDiagnosis

• Antemortem diagnosis:Antemortem diagnosis: 43.5%43.5%


– Embolic material: 16.9%Embolic material: 16.9%

– Positive blood culture:Positive blood culture: 6.4% (n=8) 6.4% (n=8)


DiagnosisDiagnosis



– Embolic material: 16.9%Embolic material: 16.9%

– Positive blood culture: 6.4% (n=8)Positive blood culture: 6.4% (n=8)

– Serology/precipitins:Serology/precipitins: 2.4%. 2.4%.


DiagnosisDiagnosis

• Other diagnostic methods?Other diagnostic methods?


DiagnosisDiagnosis


Pemán J, et al. 2nd TIMM, Berlin 2005. P-048.


DiagnosisDiagnosis


Negative galactomannan

(ELISA)

Pemán J, et al. 2nd TIMM, Berlin 2005. P-048.


MortalityMortality

• Overall mortality:Overall mortality: 92.7%92.7%


MortalityMortality

• Overall mortality: 92.7%Overall mortality: 92.7%

• Antemortem diagnosis:Antemortem diagnosis: mortality 83.0%mortality 83.0%

(p<0.0001)(p<0.0001)


MortalityMortality

• Overall mortality: 92.7%Overall mortality: 92.7%

• Antemortem diagnosis: mortality 83.0%Antemortem diagnosis: mortality 83.0%

(p<0.0001)(p<0.0001)

• Surgical treatment:Surgical treatment: 80.9%. 80.9%.


Aortic graft infectionAortic graft infection

AspergillusAspergillus graft infection graft infection

• n=22n=22



• n=22n=22

• Almost all cases: Almost all cases: immunocompetent malesimmunocompetent males



• n=22n=22

• Almost all cases: immunocompetent malesAlmost all cases: immunocompetent males

• Median Median 8 months 8 months after surgeryafter surgery



• n=22 n=22


• Median Median 8 months 8 months after surgeryafter surgery

– Candida Candida graft infections: usually < 6 weeksgraft infections: usually < 6 weeks


• n=22 n=22


• Median 8 months after surgeryMedian 8 months after surgery


• Similar to Similar to S. epidermidisS. epidermidis infectioninfection


• n=22 n=22


• Median 8 months after surgeryMedian 8 months after surgery


• Similar to Similar to S. epidermidis S. epidermidis infectioninfection

• Suture lineSuture line of a previous aortotomy. of a previous aortotomy.

Brandt SJ, et al. Am J Med 1985; 79: 259-62.

Definitive diagnostic proceduresDefinitive diagnostic procedures

• Culture of the excised aortic graftCulture of the excised aortic graft


• Culture of peripheral embolusCulture of peripheral embolus



• Culture of peripheral embolusCulture of peripheral embolus

• Biopsy of the contiguously affected vertebral disk.Biopsy of the contiguously affected vertebral disk.


TreatmentTreatment

• Effective treatment:Effective treatment: removal of the graft removal of the graft

TreatmentTreatment

• Effective treatment: removal of the graftEffective treatment: removal of the graft

• Systemic Systemic antifungal therapyantifungal therapy

TreatmentTreatment

• Effective treatment: removal of the graftEffective treatment: removal of the graft

• Systemic antifungal therapySystemic antifungal therapy

• Extra-anatomic bypassExtra-anatomic bypass through a clean field. through a clean field.

Neurosurgical infectionNeurosurgical infection


• Female, Female, 16 year-old16 year-old

• Elective Elective neurosurgeryneurosurgery for Chiari I malformation for Chiari I malformation




• Female, 16 year-oldFemale, 16 year-old

• Elective neurosurgery for Chiari I malformationElective neurosurgery for Chiari I malformation

• Long course of dexamethasoneLong course of dexamethasone



Case reportCase report• Female, 16 year-oldFemale, 16 year-old

• Elective neurosurgery for Chiari I malformationElective neurosurgery for Chiari I malformation

• Long course of dexamethasoneLong course of dexamethasone

• Clinical deteriorationClinical deterioration

– Vancomycin and cefotaximeVancomycin and cefotaxime

– Dexamethasone dose was increased.Dexamethasone dose was increased.




• CSF culture (day 18):CSF culture (day 18): few colonies of few colonies of

A. fumigatus.A. fumigatus.



Is that a contaminant?Is that a contaminant?



• Symptoms persistedSymptoms persisted





• Wound exploration:Wound exploration: sutures had dehisced sutures had dehisced





• Wound exploration: sutures had dehiscedWound exploration: sutures had dehisced

• CulturesCultures again revealed again revealed A. fumigatusA. fumigatus

• Amphotericin BAmphotericin B was started (day 28) was started (day 28)



Case reportCase report• Symptoms persistedSymptoms persisted

• Wound exploration: sutures had dehiscedWound exploration: sutures had dehisced

• Cultures again revealed Cultures again revealed A. fumigatusA. fumigatus

• Amphotericin B was started (day 28)Amphotericin B was started (day 28)

• Symptoms did not improveSymptoms did not improve

• Dural graft was removed.Dural graft was removed.



• A. fumigatus A. fumigatus in the surgical specimensin the surgical specimens




• A. fumigatus A. fumigatus in the surgical specimens in the surgical specimens

• She She dieddied 2 months after the 1 2 months after the 1stst surgery surgery



Case reportCase report• A. fumigatus A. fumigatus in the surgical specimens in the surgical specimens

• She died 2 months after the 1She died 2 months after the 1stst surgery surgery


– Abundant hyphae in the origin of the basilar artery and bilateral vertebral arteriesAbundant hyphae in the origin of the basilar artery and bilateral vertebral arteries

– Multifocal transmural destruction of arterial wallsMultifocal transmural destruction of arterial walls



Case reportCase report• A. fumigatus A. fumigatus in the surgical specimens in the surgical specimens

• She died 2 months after the 1She died 2 months after the 1stst surgery surgery


– Abundant hyphae in the origin of the basilar artery and bilateral vertebral arteriesAbundant hyphae in the origin of the basilar artery and bilateral vertebral arteries

– Multifocal transmural destruction of arterial wallsMultifocal transmural destruction of arterial walls

– No other focus of aspergillosis was found.No other focus of aspergillosis was found.



Aspergillosis after neurosurgeryAspergillosis after neurosurgery

• n=25n=25



• n=25n=25

• Male sex:Male sex: 44.0% 44.0%


• n=25 n=25

• Male sex: 44.0%Male sex: 44.0%

• Steroids:Steroids: 52.0%52.0%



• n=25 n=25

• Male sex: 44.0%Male sex: 44.0%

• Steroids: 52.0%Steroids: 52.0%

• All proven cases: All proven cases: A. fumigatus.A. fumigatus.



• Median Median 3 months after surgery3 months after surgery (<1 to > 12) (<1 to > 12)



• Median 3 months after surgery (<1 to > 12) Median 3 months after surgery (<1 to > 12)

• Different presentationsDifferent presentations

– MeningitisMeningitis

– CNS abscessCNS abscess

– Mycotic aneurismsMycotic aneurisms

– Infarction.Infarction.




– Abscess examination:Abscess examination: 36.0% 36.0%


www.aspergillus.man.ac.uk/secure/image_library/invpulmonaryasp/cerebralaspkh.htm



– Abscess examination: 36.0%Abscess examination: 36.0%

– Culture of CSF:Culture of CSF: 20.0%20.0%



• Antemortem diagnosis: 64.0%Antemortem diagnosis: 64.0%

– Abscess examination: 36.0%Abscess examination: 36.0%

– Culture of CSF: 20.0%Culture of CSF: 20.0%

• Mortality:Mortality: 68.0%. 68.0%.



Trans-sphenoidal surgeryTrans-sphenoidal surgery

Endo T, et al. Surg Neurol 2001; 56: 195-200.


Wound infectionWound infection


DefinitionsDefinitions

• Skin or subcutaneous tissueSkin or subcutaneous tissue of the incision of the incision



• Skin or subcutaneous tissue of the incisionSkin or subcutaneous tissue of the incision

• When both superficial and deep When both superficial and deep incision sites: incision sites:

classified as deep surgical site infectionclassified as deep surgical site infection



• Skin or subcutaneous tissue of the incisionSkin or subcutaneous tissue of the incision

• When both superficial and deep incision sites: When both superficial and deep incision sites:

classified as deep surgical site infectionclassified as deep surgical site infection

• Similar to CDC’s criteria for SSI.Similar to CDC’s criteria for SSI.



• The wound itself had to be The wound itself had to be non-healing with non-healing with

standard antibioticsstandard antibiotics, and other pathogens , and other pathogens

were absent or minimally presentedwere absent or minimally presented



• The wound itself had to be non-healing with standard The wound itself had to be non-healing with standard

antibiotics, and other pathogens were absent or minimally antibiotics, and other pathogens were absent or minimally

presentedpresented

• Topographic relation Topographic relation between the surgery and the infectionbetween the surgery and the infection

DefinitionsDefinitions• The wound itself had to be non-healing with standard antibiotics, The wound itself had to be non-healing with standard antibiotics,

and other pathogens were absent or minimally presentedand other pathogens were absent or minimally presented

• Topographic relation between the surgery and the infectionTopographic relation between the surgery and the infection

• n=22.n=22.

The first case reportedThe first case reported

• 19331933

Frank L, Alton OM. JAMA 1933; 100: 2007-8.


The first case reportedThe first case reported

• 19331933


• Operated on for an abdominal tumourOperated on for an abdominal tumour



The first case reportedThe first case reported• 19331933



• After 16 days:After 16 days: ulcer under the dressing ulcer under the dressing

• No systemic manifestationsNo systemic manifestations



The first case reportedThe first case reported• 19331933



• After 16 days: ulcer under the dressingAfter 16 days: ulcer under the dressing

• No systemic manifestationsNo systemic manifestations

• A. nigerA. niger grew in the surgical dressings covered with a dark powder. grew in the surgical dressings covered with a dark powder.



ParticularitiesParticularities

• Median Median 17 days after surgery 17 days after surgery (<7 to 180)(<7 to 180)



• Median 17 days after surgery (<7 to 180)Median 17 days after surgery (<7 to 180)

• Many patients were Many patients were immunosuppressedimmunosuppressed



• Median 17 days after surgery (<7 to 180)Median 17 days after surgery (<7 to 180)

• Many patients were immunosuppressedMany patients were immunosuppressed

• Aspergillus Aspergillus species:species:

– A. fumigatusA. fumigatus: 42.1%: 42.1%

– A. flavusA. flavus: 36.8%: 36.8%

– A. nigerA. niger: 10.5%: 10.5%

– A.A. spp: 10.5% spp: 10.5%


Risk of disseminationRisk of dissemination

• Aggressive combined medical therapy and debridement is Aggressive combined medical therapy and debridement is

required for all patients.required for all patients.


OutbreaksOutbreaks

• Outbreak of wound aspergillosisOutbreak of wound aspergillosis

– Contamination during hospital construction of the outside packages of dressing suppliesContamination during hospital construction of the outside packages of dressing supplies

Bryce EA, et al. Infect Control Hosp Epidemiol 1996; 17: 170-2.


OutbreaksOutbreaks



• Outbreaks of cutaneous aspergillosisOutbreaks of cutaneous aspergillosis

– Wound dressing and tape should be culturedWound dressing and tape should be cultured



OutbreaksOutbreaks



• Outbreaks of cutaneous aspergillosisOutbreaks of cutaneous aspergillosis

– Wound dressing and tape should be culturedWound dressing and tape should be cultured

• A. flavus A. flavus sternal wound infection coinciding with sternal wound infection coinciding with hospital renovation activities.hospital renovation activities.



Risk factorsRisk factors

• Chronic lung diseaseChronic lung disease

– Independent risk factorIndependent risk factor for for A. fumigatus A. fumigatus sternal wound infection after open-heart surgerysternal wound infection after open-heart surgery

Richet HM, et al. Am J Epidemiol 1992; 135: 48-58.




– Independent risk factor for Independent risk factor for A. fumigatus A. fumigatus sternal wound infection after open-heart surgerysternal wound infection after open-heart surgery

– A. fumigatusA. fumigatus grew at the same time from the grew at the same time from the bronchial washingbronchial washing of one patient of one patient





– Independent risk factor for Independent risk factor for A. fumigatus A. fumigatus sternal wound infection after open-heart surgerysternal wound infection after open-heart surgery

– A. fumigatusA. fumigatus grew at the same time from the bronchial washing of one patient grew at the same time from the bronchial washing of one patient

– Colonised patients may be at increased risk.Colonised patients may be at increased risk.



Ophthalmological Ophthalmological surgerysurgery


Ophthalmological surgeryOphthalmological surgery

• Usually keratitisUsually keratitis; rarely endophthalmitis; rarely endophthalmitis

Tabbara KF, et al. Ophthalmology 1998; 105: 522-6. Sridhar MS, et al. Am J Ophthalmol 2000; 129: 802-4.



• Usually keratitis; rarely endophthalmitisUsually keratitis; rarely endophthalmitis

• Many different proceduresMany different procedures

– PPenetrating keratoplastyenetrating keratoplasty

– Radial keratotomyRadial keratotomy

– Excimer laser photorefractive Excimer laser photorefractive

keratectomykeratectomy

– Laser-assisted in situ Laser-assisted in situ

keratomileusiskeratomileusis

– Pterygium excisionPterygium excision

– Cataract surgeryCataract surgery

– Scleral buckling proceduresScleral buckling procedures

– Hydroxyapatite orbital Hydroxyapatite orbital

implant surgeryimplant surgery

– Sutureless surgerySutureless surgery

– TrabeculectomyTrabeculectomy



• Sampling at the site of infection:Sampling at the site of infection: best chance for best chance for

obtaining a positive cultureobtaining a positive culture



• Sampling at the site of infection: best chance for obtaining a positive cultureSampling at the site of infection: best chance for obtaining a positive culture

• Source of infection:Source of infection:

– Hospital constructionHospital construction






– Contaminated irrigating fluids used during surgeryContaminated irrigating fluids used during surgery






– Contaminated irrigating fluids used during surgeryContaminated irrigating fluids used during surgery

– Many occurred after Many occurred after non-surgical corneal trauma.non-surgical corneal trauma.


Surgical dental Surgical dental procedureprocedure


Surgical dental procedureSurgical dental procedure

• Connection between Connection between endodontic treatmentendodontic treatment and non- and non-

invasive sinus aspergillosisinvasive sinus aspergillosis



• Connection between endodontic treatment and non-invasive sinus aspergillosisConnection between endodontic treatment and non-invasive sinus aspergillosis

• Obturating pastes containing Obturating pastes containing zinc oxidzinc oxid within the maxillary antrum within the maxillary antrum



• Connection between endodontic treatment and non-invasive sinus aspergillosisConnection between endodontic treatment and non-invasive sinus aspergillosis

• Obturating pastes containing zinc oxid within the maxillary antrumObturating pastes containing zinc oxid within the maxillary antrum

• Surgical treatmentSurgical treatment

– Removal of all materialRemoval of all material

– Promote aerationPromote aeration

– Antifungals only if invasion.Antifungals only if invasion.


TreatmentTreatment


TreatmentTreatment

• Optimal therapy:Optimal therapy: not specifically studied not specifically studied


TreatmentTreatment

• Optimal therapy: not specifically studiedOptimal therapy: not specifically studied

• Excision of the infected tissueExcision of the infected tissue


TreatmentTreatment



• Placement of a Placement of a new prosthesisnew prosthesis in a non-infected field in a non-infected field


TreatmentTreatment



• Placement of a new prosthesis in a non-infected fieldPlacement of a new prosthesis in a non-infected field

• Systemic antifungal agentsSystemic antifungal agents


TreatmentTreatment





• Longer term Longer term oral therapyoral therapy


TreatmentTreatment





• Longer term oral therapyLonger term oral therapy

• Duration:Duration: unknown. unknown.


PreventionPrevention


Main sources of infectionMain sources of infection

• Contaminated graftsContaminated grafts




• Contaminated suturesContaminated sutures




• Contaminated suturesContaminated sutures

• Intra-operative dispersion of spores.Intra-operative dispersion of spores.


Linking the infection with Linking the infection with the surgical room the surgical room

• ““Pigeon excretaPigeon excreta in the immediate vicinity of the ventilator intake in the immediate vicinity of the ventilator intake

port were found to harbour large numbers of port were found to harbour large numbers of Aspergillus sporesAspergillus spores””

Gage AA, et al. Arch Surg 1970; 101: 384-87.Gage AA, et al. Arch Surg 1970; 101: 384-87.

Linking the infection with Linking the infection with the surgical room the surgical room

• ““Air conditioner cooling coils and pigeon droppings on the ledges outside Air conditioner cooling coils and pigeon droppings on the ledges outside

the suite were found to harbour Aspergillus spores in large amounts”.the suite were found to harbour Aspergillus spores in large amounts”.

Mehta G. J Hosp Infect 1990; 15: 245-53.Mehta G. J Hosp Infect 1990; 15: 245-53.


Infection acquired in the ICUInfection acquired in the ICU

Carlson GL, et al. J Infect 1996; 33: 119-21Carlson GL, et al. J Infect 1996; 33: 119-21.

• Multiple abdominal visceral infectionMultiple abdominal visceral infection by by A. A.

fumigatusfumigatus occurred occurred afterafter laparostomylaparostomy



Carlson GL, et al. J Infect 1996; 33: 119-21Carlson GL, et al. J Infect 1996; 33: 119-21.

Dark patches on the liver invading liver capsule

• Multiple abdominal visceral infectionMultiple abdominal visceral infection by by A. A.

fumigatusfumigatus occurred occurred afterafter laparostomylaparostomy


• Multiple abdominal visceral infection by Multiple abdominal visceral infection by A. fumigatusA. fumigatus occurred after laparostomy occurred after laparostomy

• Sampling of air from the ICU yielded one isolate that Sampling of air from the ICU yielded one isolate that matched matched the patient's isolates.the patient's isolates.

Carlson GL, et al. J Infect 1996; 33: 119-21.Carlson GL, et al. J Infect 1996; 33: 119-21.


• Grilles of heat exchanger Grilles of heat exchanger used to maintain used to maintain

extracorporeal blood at the proper extracorporeal blood at the proper

temperature.temperature.

Diaz-Guerra TM, et al. J Clin Microbiol 2000; 38: 2419-22.Diaz-Guerra TM, et al. J Clin Microbiol 2000; 38: 2419-22.

Fomites as a reservoirFomites as a reservoir


Diaz-Guerra TM, et al. J Clin Microbiol 2000; 38: 2419-22.Diaz-Guerra TM, et al. J Clin Microbiol 2000; 38: 2419-22.

RAPD patternsRAPD patterns• Three primers Three primers

(A, B, C)(A, B, C)

• 1, 2:1, 2:

– EnvironmentalEnvironmental

• 3: 3:

– Aortic prosthesisAortic prosthesis


• Tap water:Tap water: not on surgical wounds not on surgical wounds



• Tap water: not on surgical woundsTap water: not on surgical wounds

• Conventional ventilation and filters Conventional ventilation and filters onlyonly remove airborne particles remove airborne particles 5 5 mm




• Conventional ventilation and filters only remove airborne particles Conventional ventilation and filters only remove airborne particles 5 5 mm

• Laminar airflow systems and HEPA filtrationLaminar airflow systems and HEPA filtration






– Lack of dataLack of data revealing survival benefit revealing survival benefit

– CostsCosts






– Lack of data revealing survival benefitLack of data revealing survival benefit

– CostsCosts

– Lack of consensusLack of consensus about the level of airborne conidia at which the risk can be numerically defined. about the level of airborne conidia at which the risk can be numerically defined.


Heinemann S, et al. J Hosp Infect 2004; 57: 149-55.

HEPAHEPA

filtrationfiltration

Offices, meeting rooms, Offices, meeting rooms, lounges, utilities, lounges, utilities,

storage roomsstorage rooms

HEPA filtration is importantHEPA filtration is importantbut maybe not enoughbut maybe not enough

HEPAHEPA

filtrationfiltration


Outbreak of Outbreak of A. flavusA. flavus wound infectionwound infection

Heavily Heavily contaminated areascontaminated areas


Outbreak of Outbreak of A. flavusA. flavus wound infectionwound infection

Water leakageWater leakage


RAPD resultsRAPD results

• Investigating Aspergillus infections

Fox BC. Am J Infect Control 1990; 18: 300-6.Fox BC. Am J Infect Control 1990; 18: 300-6.

PenicilliumPenicillium in the OR in the OR


• Investigating Aspergillus infections

• Heavy contamination by Penicillium in the heating, ventilation, and air conditioning (HVAC) system

of the OR.





Terminal units lined Terminal units lined with fibreglass with fibreglass served as a served as a substrate for substrate for fungal growth.fungal growth.


Lutz G, et al. Clin Infect Dis 2003; 37: 786-93.Lutz G, et al. Clin Infect Dis 2003; 37: 786-93.

Deteriorated ventilation systemsDeteriorated ventilation systems

ConclusionConclusion



• Underappreciated problemUnderappreciated problem




• Mortality:Mortality: high in non-cutaneous infections high in non-cutaneous infections




• Mortality: high in non-cutaneous infectionsMortality: high in non-cutaneous infections

• Different organs and surgical proceduresDifferent organs and surgical procedures






• Usually Usually indolentindolent






• Usually indolentUsually indolent

• Combined aggressive Combined aggressive medical and surgical therapy.medical and surgical therapy.



• Prevention:Prevention:

– Special care with the ventilation system in the surgical roomSpecial care with the ventilation system in the surgical room



• Prevention:Prevention:

– Special care with the ventilation system in the surgical roomSpecial care with the ventilation system in the surgical room

– Proper storage and disinfection of surgical material.Proper storage and disinfection of surgical material.


AcknowledgmentsAcknowledgments

• David W. DenningDavid W. Denning

AcknowledgmentsAcknowledgments• David W. DenningDavid W. Denning

• Fungal Research TrustFungal Research Trust

AcknowledgmentsAcknowledgments• David W. DenningDavid W. Denning

• Fungal Research TrustFungal Research Trust

• CAPESCAPES

[email protected]@manchester.ac.uk

postoperative aspergillosis alessandro c. pasqualotto school of medicine, the university of...

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