Detailed discussion of nosocomial fungal infections and yeast identification scheme.

1. Nosocomial
fungal
infections
Dr. ROUMI GHOSH
PG, 3rd Yr, MAMC,
New Delhi

2. What’s meant by Nosocomial infections or
Healthcare-associated Infections ?
• Comes from 2 Greek words. “Nocos”= disease + “komeion”
=take care of
• A localized or systemic condition
1) that results from adverse reaction in presence of an
infectious agent(s) or its toxin(s) and
2) that was not present or incubating at the time of admission
to the hospital or other health care facility.
• Infection are considered nosocomial if they first appear 48 hrs
or more after hospital admission without proven prior
incubation or within 30 days after discharge.
• This also includes occupational infections among staff of the
facility and patient companions.

3. • Two special situations in which an infection is
considered nosocomial:
(a) infection that is acquired in the hospital but
does not become evident until after hospital
discharge
(b) infection in a neonate that results from passage
through the birth canal
• But infection transplacentally (e.g.,
toxoplasmosis, rubella, cytomegalovirus, or
syphilis), becomes evident after birth not
considered nosocomial.

4. • There are two conditions that are not
infections:
1)Colonization, presence of microorganisms
(on skin, mucous membranes, in open
wounds, or in excretions or secretions) not
causing adverse clinical signs or symptoms.
2)Inflammation, a condition that results from
tissue response to injury or stimulation by
noninfectious agents, such as chemicals.

5. Factors associated with rising trend of
nosocomial infections:
• Crowded hospital conditions
• Increasing number of people with
compromised immune systems
•New microorganisms
•Increasing bacterial resistance

6. Why do nosocomial infection occur?
Presence of microbes in
hospital environment
Immunocompromised
patients
Transmission between
staff and patients and
among patients
Nosocomial infection

7. Five major routes of transmission
1. Contact:
Direct (person-person)
Indirect (through an object)
2. Droplet
3. Airborne
4. Common vehicle
5. Vector borne
The same organism may be transmitted by more than one route

8. • Variety of fungi of medical importance were
recovered from cockroaches (Blattella germanica)
from hospital and residential area.
Cockroaches (Blattella germanica) as carriers of microorganisms of medical
importance in hospitals. R. FOTEDAR', U. BANERJEE SHRINIWAS' AND A. VERMA2.
Epidemiol. Infect. (1991)t 107, 181-187 181. All India Institute of Medical Sciences,
New Dehli 110029, India

9. Types of infections
CAUTI
35%
Surgical wound
infection
19%
Central Line-
associated
Bloodstream
Infection (CLABSI)
15%
12%
others
5%
Antibiotic associated diarrhea
Catheter-associated
Urinary Tract Infections
(CAUTI)
Pneumonia
14%
In general 5–10% of patients develop nosocomial infections.
Magnifies several folds depending on high risk patient population

10. Fungal infections account for 9% of all nosocomial
infections.
Wider use of aggressive modalities of treatments
hematopoietic stem cell transplantation (HSCT)
solid organ transplantation (SOT)
new chemotherapeutic & broad spectrum
antimicrobial agents
immunomodulatory agents
Increases immunocompromised patient population at risk
for invasive fungal infection
Incidence of infections in health care facilities by moulds
risen dramatically in recent years more in developing
countries.

11. Frequently identified risk factors for fungemia in
hospitalized patients
• Antimicrobial agents: Number and Duration
• Adrenal corticosteroid
• Chemotherapy
• Hematological/solid organ malignancy
• Previous colonization
• Indwelling catheter
• Central venous catheter
• Pressure transducer/Swan-Ganz
• Total parenteral nutrition
• Neutropenia (polymorphonuclear cells,500/mm3)
• Extensive surgery or burns
• Assisted ventilation
• Hospitalization or intensive care unit stay
• Hemodialysis
• Malnutrition
• Hospitalization during construction activity

12. The majority of nosocomial fungal infections are
caused by Candida spp. and Aspergillus spp.

13. EMERGING NOSOCOMIAL FUNGAL PATHOGENS
Yeasts Moulds
Hyalohyphomycosis
Aspergillus
Mucormycotina
Fusarium
Acremonium
Scedosprorium
Pseudallescheria
Paecilomyces
Phaeohyphomycosis
Exserohilum
Cladophialophora
Curvularia
Alternaria
Bipolaris
Chaetomium
Candida
Trichosporon
Rhodotorula
Saccharomyces
Malassezia
Pichia
Geotrichum
Cryptococcus

14. YEAST & YEAST LIKE FUNGI

15. Candida
Spectrum of diseases caused:
 Catheter associated UTI (CAUTI)
 Catheter related blood stream infection (CRBSI)
 Antibiotic associated diarrhea
 And other disseminated diseases: arthritis,
osteomyelitis, endocarditis, endophthalmitis,
meningitis.

16. • C. albicans is the mc cause of invasive fungal
infections in hospital settings (50% - 70%)
• Emergence of non-albicans species due to
selection pressure (overall 46%)
• Global Antifungal Surveillance Program-
C. albicans most common (63–70%)
C. glabrata (44%),
C. tropicalis (6%), and
C. parapsilosis (5%).
• Fluconazole resistance was noted in
• C. krusei (78%)
• C. glabrata (16%)
• C. guilliermondii (11%)

17. Candida spp. causing nosocomial infections
Candida species Affected patient population
C. tropicalis bone marrow transplantation
hematologic malignancies
C. glabreta patients with solid tumors
C. parapsilosis Parenteral nutrition
Post-op endophthalmitis by contaminated iol-irrigating Sol
C. krusei Hematologic malignancies, Granulocytopenia
Having antifungal prophylaxis
Others
C. kefyr
C. lusitaniae
C. guilliermondii
C. dubliniensis
C. rugosa
C. pelliculosa
C. Lipolytica
C. viswanathii
C. nivariensis
hematologic malignancies
Catheter-related BSI
can be acquired from hospital gardens or potted plants

18. Reservoirs and Modes of Transmission
• Endogenous:
• major reservoir: g.i. tract
skin
• through a breakdown in
mucosal or epithelial tissue
colonized flora is the
source of infection
• Strategies for prevention:
decrease mucosal
colonization
decreased use of broad-
spectrum antimicrobials
• Exogenous:
• contaminated infusates,
• hands of health care
workers
• indwelling catheter
• MC species isolated from
hands of nurses was
C. parapsilosis

19. Reasons for Candida’s virulence
1. Versatility in adaptation to various different habitats, and
formation of biofilms.
– C. albicans forms fungal biofilms most often,
– non-albicans Candida species also, specially
C. parapsilosis or C. tropicalis.
2. Secretion aspertyl proteinase (Sap): facilitate hyphal entry
3. Phenotypic switching: from budding yeast cells to hyphae
or pseudohyphae reduce phagocytosis

20. Fluconazole Voriconazole AMP-B Caspofungin
C glabrata Susceptible (dose
dependent)
to resistant
Susceptible (dose
dependent)
to resistant
Susceptible to
intermediate
Susceptibility
Susceptible*
C tropicalis Susceptible Susceptible Susceptible Susceptible*
C parapsilosis Susceptible Susceptible Susceptible Susceptible to
resistant*
C krusei Resistant Susceptible (dose
dependent)
to resistant
Susceptible to
intermediate
Susceptibility
Susceptible
Candida kefyr Susceptible Susceptible Susceptible Susceptible*
C lusitaniae Susceptible Susceptible Resistant Susceptible*
C dubliniensis Susceptible (71%)
to resistant
Susceptible(91%) Susceptible Susceptible
Candida rugosa Very low activity Low activity Susceptible Susceptible
C guilliermondii Low activity Susceptible Susceptible Susceptible

21. • C parapsilosis, C lipolytica, C lusitaniae, C
glabrata and C tropicalis can cause
breakthrough mycoses despite prophylactic or
therapeutic use of echinocandins.
• Reports of reduced susceptibility or resistance
in
– immunosuppression,
– recurrent candidaemia, and
– prolonged exposure to echinocandins.
• Resistance to amphotericin B appears to be the
hallmark of C. lusitaniae

22. Drug-resistant fungi new hospital menace
Feb 4, 2013
• NEW DELHI: After the superbug, it might soon be the 'superfungi'.
The organisms, known to be opportunistic pathogens causing
infection in critically-ill patients, are fast turning drug-resistant.
• A study by microbiologists at Ganga Ram Hospital revealed several
new species of fungi, become difficult to treat even with most
potent antifungal medicine, such as amphotericin B.
• One particular species C. haemulonii, has also proved
untreatable.

23. Catheter-associated UTI
• 10-15% nosocomial UTI are due to Candida spp.
• Always in a diagnostic dilemma whether contamination,
colonization or true infection
• No reliable methods of differentiating colonization or true UTI with
Candida.
• Candida infection is more common during extreme of ages.
• Hematogenous spread is the most common route of renal
candidiasis.
• Ascending infection follows catheterisation, introduce peri-urethral
commensal and allow migration into bladder along surface.
• Risk of developing candemia following candiduria varies (2-50%).

24. • Risk factors:
 urinary tract instrumentation.
(27% of all indwelling catheter associated UTI)
 Use of antibiotics> suppress endogenous flora> colonization by
candida
 Previous surgical procudure
 Diabetes mellitus> glycosuria> increase fungal growth
 Predominant species isolated from our hospital:
C. tropicalis (46%), C. albicans (30%),C. kefyr, C. krusei, C.
sphaerica.
 In a recent study in GB Pant Hospital shows prevalence of 71.4%
non-albicans Candida spp. causing UTI in ICU patients.
 Mixed isolates found in 10% of patients.

25. Diagnosis:
Positive candida urine
culture
colonization
Confirm by 2nd urine
sample
Check for pyuria
Absent
If colony count < 103
cfu/ml
Rule out Candida infection
Present
Candida infection
Localise anatomic site of
infection
Asymptomatic
candiduria Candida cystitis
Renal
candidiasis
> 10⁵ CFU/ml+
Urine sample from
asymptomatic pts without indwelling catheter

26. Urine sample from pts long-term indwelling or intermittent catheters
•Diagnosis of a UTI due to Candida species very difficult.
•Pyuria or quantitative urine cultures for UTI of little use.
Catheterisation
low-grade Inflammation
Presence of WBCs
As few as 10⁴ cfu/mL may mean
infection
2x10⁴-10⁵ cfu/mL may mean only
colonization
Many tried to co-relate with
•presence of pseudohyphae
•antibody-coated yeasts in the urine
•casts containing yeasts

27. Diagnosis:
• Collection of second sample
• Second sample collection after changing catheter
or by suprapubic aspiration
Helps to rule out contamination from perineal
colonization or asymptomatic adherence on
catheter or foreign bodies

28. Bundled Interventions to Prevent Urinary Tract Infections
• Place bladder catheters only
when absolutely needed, not
solely for the provider's
convenience.
• Use aseptic technique for
catheter insertion and urinary
tract instrumentation.
• Minimize manipulation or
opening of drainage systems.
• Ask daily: Is the bladder catheter
needed?
• Remove catheter if not needed.

29. Management:
• Removal of catheter is strongly recommended as
soon as possible.
• Amphotericin B bladder irrigation highly effective for
Candida cystitis
• Oral fluconazole, 200 to 400 mg/day for 14 days.
• In case of C. glabrata or C. krusei: Flucytocine shows
excellent activity with high urinary concentration
• Echinocandins poor glomerular filtration, not very
useful.
• High dose i.v. Ampho B or fluconazole recommended
for pyelonephritis, but duration is not determined.
• Nephrostomy tube can be used to administer high
dose of drugs locally.

30. Blood stream infection:
• In developed countries Candida species are 4th
most common cause of BSI.
• A study from Maulana Azad Medical
College, found an incidence rate of 6.9%
for Candida species in BSI.
• Study from UCMS gave a prevalence rate of 18%
for Candida species among blood culture isolates
• AIIMS, New Delhi, found a prevalence rate of 6%
for Candida species in a 5-year study (2001-
2005).

31. • C. albicans, most common species from BSI worldwide
• Among the non-albicans species, C. glabrata has
emerged as an important opportunistic pathogen
worldwide.
• It for 75% of cases of fungemia among patients
receiving fluconazole as antifungal prophylaxis.
• In India, C. tropicalis is now the most common cause of
nosocomial candidemia. (67-90%). Mainly among
hematologic malignancies.
• C. parapsilosis found to be increasingly implicated in
BSI after placement of intravascular devices and TPN
infusion.

32. • Highest mortality was found among patients
with C. krusei infection (52.9%)
• C. parapsilosis infection had the lowest
mortality rate of 23.7%

33. Diagnosis:
• Most reliable diagnostic method of CRBSI:
1. Semiquantitative (roll plate) >15 cfu
2. Quantitative or
(vortex or sonication methods)
catheter culture techniques > 10²cfu
+
• For rapid diagnosis: use of acridine orange stains
• Paired cultures of blood drawn through the iv
catheter and percuteneous
1. CFU from CVS 5–10-fold greater
2. Positive culture form CVS at least 2 h earlier
signs of local or systemic infection

34. Bundled Interventions" to Prevent Common Health Care–
Associated Infections
• Prevention of Central Venous Catheter
Infections:
1) Educate personnel about catheter insertion
and care.
2) Use chlorhexidine to prepare the insertion
site.
3) Use maximal barrier precautions during
catheter insertion.
4) Consolidate insertion supplies (e.g., in an
insertion kit or cart).
5) Use a checklist to enhance adherence to
the bundle.
6) Empower nurses to halt insertion if asepsis
is breached.
7) Cleanse patients daily with chlorhexidine.
8) Ask daily: Is the catheter needed? Remove
catheter if not needed or used.

35. • New 2011 CDC guidelines has announced new
guidelines to reduce the risk of catheter-
associated infections.
• The guidelines now designate treatment with
chlorhexidine gluconate-impregnated sponge

36. Prevention and Therapy
• Removal of Central i.v. catheters in patients with
candidemia
• I. V. AmB or fluconazole, continued for 14 days
after blood cultures have yielded no yeast
• Patients with candidemia and metastatic foci
(eg, eye, bone, heart, liver, spleen) require a
longer duration of therapy.
• Prophylactic fluconazole among selected
leukemia or bone marrow transplant patients
effective for all except C. krusei
• Posaconazole or echinocandins are preferred for
the initial treatment if C. glabrata or C. krusei is
identified or suspected

37. Antibiotic-associated diarrhea:
• Patients receiving longterm antimicrobial
agents commonly develop a secretory non-
bloody diarrhea
 C. difficile toxin-negative
 evidence of intestinal overgrowth of Candida spp.
• A study from our department reported yeast
from 26.7% of nosocomial diarrhea cases.
• Respond to oral nystatin therapy
• Stoppage of persistent use of intravenous
antimicrobial agents

38. Trichosporon species:
T. asahii, T. mucoides, T. asteroides
• Most common non-candidal yeast infection in
hematologic cancer patients with mortality
>80%

39. Trichosporon species: T. asahii, T. mucoides, T. asteroides
• Causes superficial infection of hair shafts, white piedra.
• Trichosporonosis (bloodstream infections, severe skin
infections, endocarditis, peritonitis), becoming more
common in hospitalized patients.
• Catheter related fungaemia, occur as a breakthrough
invasive infection on antifungal therapy with high
mortality.
• Endophthalmitis after cataract extraction, endocarditis
following prosthetic cardiac valves insertion also reported.
• Because of shared Ag with the capsule of Cryptococcus
neoformans, a positive cryptococcal latex test can occur in
patients with trichosporonosis.

40. • Abundant pseudohyphae,
• arthroconidia
• Numerous spherical to oval budding
blastoconidia from both corner of
arthroconidia
• “Rabbit ears” appearence

41. Fluconazole Voriconazole AMP-B Caspofungin Flucytosine
Trichosporon
asahii
Low activity Susceptible Resistant Resistant Resistant
Trichosporon
beigelii
(cutaneum)
Low activity Low activity Resistant Resistant Resistant
Anifungal sensitivity
•Clinical and in-vitro studies, suggest that azoles,
especially voriconazole and posaconazole, have
greatest effectiveness against Trichosporon. spp

42. Rhodotorula species: R. mucilaginosa
• In immunocompetent patients:
• Endophthalmitis
• Peritonitis (continuous ambulatory peritoneal
dialysis)
• Overall mortality from rhodotorula fungaemia is 15%.
•Previously regarded as non-pathogenic.
•Emerged as opportunistic pathogens
•Most cases of rhodotorula infection are
fungaemia associated with catheters,
endocarditis, and
Meningitis.

43. Fluconazole Voriconazole AMP-B flucytosine Caspofungin
Rhodotorula
species
Very low
activity
Variable
susceptibility
/
very low
activity
Susceptible Susceptible Resistant
• Rhodotorula species, often resistant to
fluconazole and voriconazole.
• Amphotericin is the antifungal agent of choice
for treatment of rhodotorula infections.
Anifungal sensitivity

44. Malassezia species: M. furfur and M. pachydermatis
• Causative agent of Pityriasis versicolor and seborrhoeic dermatitis
• Frequently observed as nosocomial pathogens in recent times.
• Causes invasive infections especially in NICU patients.
• Central line used for infusion of the lipid emulsion tend to grow M.
furfur from LBW neonate and adult patients
Globose, oblong-ellipsoidal to cylindrical yeast
cells with broad base budding from the same
site at one pole (unipolar)
• Unable to synthesize
long-chain fatty acids and
requires exogenous lipid for
growth

45. • Detection enhanced by growing the specimen on
Sabouraud agar covered with a thin layer of sterile olive oil
(lipophilic)
• Alternatively to use specialized media like Dixon's agar
which contains glycerol mono-oleate
• Removal of the catheter and cessation of lipid infusion
main stay of treatment
• Systemic antifungal treatment with ampho B, ketoconazole,
itraconazole, voriconazole reserved for persistent infection

46. Pichia anomala (Hansenula anomala)
• P. anomala first reported as pathogen in nosocomial
outbreak among 379 neonates in Chandigarh (Chakrabarti et
al 2001)-
fungemia, interstitial lung disease, endocarditis, enteritis
• Fungaemia associated with a CVC is most common,
mainly among neonates and ICUs.
• Later outbreak reported in paediatric ICU in Brazil in 2005
Saprophytes in environment,
also found In milk, cheese, yoghurt
production of one to four hat-shaped ascospores

47. Fluconazole Voriconazole AMP-B Caspofungin
P anomala Fluconazole:
low activity;
itraconazole:
very low activity
Susceptible Susceptible Susceptible
•In vitro, amphotericin, fluconazole, voriconazole,
and caspofungin have activity against P anomala,
although high drug concentrations required for
inhibition;
•itraconazole is poorly active against this yeast.

48. Saccharomyces cerevisiae:
• Use of live yeast capsules
(Saccharomyces boulardii), taken
for prevention of Clostridium
difficile associated diarrhoea, leads
to Fungaemia.
• Patients at risk:-in ICU,with CVC
- had broad spectrum antibiotics
• Very few data are available for drug
efficacy,
• amphotericin and voriconazole
seem to be active in vitro.
Probiotic!!

49. Cryptococcus neoformans
• Nosocomial transmission quite rare.
• Pulmonary cryptococcosis case Direct
inhalation 2ndry infection in close contact
• Needlestick injury localized cuteneous
cryptococcal granuloma in lab worker
• Proper sterilization hospital equipment
mandatory.
Also...

50. Principal Criteria and Tests for Identifying Yeasts
1. Culture characteristics - Colony color, shape, texture
2. Asexual structures:
a) Shape and size of cells
b) Bipolar, fission, multipolar or unipolar "budding"
c) Absence or presence of arthroconidia, ballistoconidia, blastoconidia, clamp
connections, endoconidia, germ tubes, hyphae, pseudohyphae, or sporangia and
sporgangiospores.
3. Sexual structures - Arrangement, cell wall ornamentation, number, shape and size of
ascospores or basidiospores
4. Physiological studies
a) Sugar Assimilation
b) Sugar Fermentation
c) Cycloheximide resistance
d) Tetrazolium reduction test
e) Diazonium Blue B test
f) Nitrogen utilization
g) Urea hydrolysis
h) Temperature studies
i) CHROME Agar

51. YEAST MORPHOLOGY
Brown to black
colony
Direct Mount Yeast only Phaeococcomyces
Yeast and
hyphae
Aureobasidium
Exophiala
Wangiella
Pink to red
colony
Satellite colonies Present Forcibly
discharged
conidia
Sporobolomyces
Absent Urease+
Capsule+
Inositol-
Rhodotorula
White, creamy
colony
Germ Tube Test Positive C albicans
C dubliensis
Negative Other Candida
Moist mycelial
colony
Direct Mount Arthroconidia Blastoconidia Trichosporon
Geotrichum

52. If Germ Tube test Negative
Corn Meal Agar or Rice Starch Agar
Incubate at 25 C X 2-3 days
Only yeasts present Hypae, Pseudohypae
Or both present
C. Glabrata
C. Famata
Cryptococcus
Rhodotorula
Ascomycetous yeasts

53. Chlamydospore present
(thick wall, refractile, round)
Single, terminal
Chlamydospore
Terminal, cluster of
Chlamydospore
C. albicans C. dubliensis
Arthroconidia present
Blastoconidia present
Trichosporon
Rabbit ears” appearence
Geotrichum
“Hockey stick” appearence
No Chlamydospore
No Arthroconidia
Other Candida
Saccharomycec
Pichia
Malassezia
Hypae, Pseudohypae
Or both present
Ascospore +
On Malt extract agar
Or Na-acetate agar
At 25 C
Ascospore are acid fast
Spaghetti & meat ball app

54. Candida species Identification
C.albicans
C.dubliniensis
C.glabrata
C.krusei
C.kefyr
C.parapsilosis
C.tropicalis
C.guilliermondii
C.famata
C.lipolytica
Chlamydospore + + - - - - - - - -
Germ tube + + - - - - - - - -
Pellicle On broth + +
Urease + +
Fermentation
Glu
Mal
Suc
Lac
Gal
Tre
F
F
-
-
F
F
F
-
-
F
F
F
-
-
-
-
F
F
-
-
-
-
-
F
-
F
F
F
-
F
-
-
-
-
-
F
F
F
-
F
F
F
-
F
-
F
F
W
-
W
-
-
W
-
-
-
-
-
-
Assimilation
Glu
Mal
Suc
Lac
Tre
+
+
+
+
+
+
+
-
-
-
+
-
-
-
+
+
-
-
-
-
+
-
+
+
-
+
+
+
-
+
+
+
+
-
+
+
+
+
-
+
+
+
+
+
+
+
-
-
-
-

55. MOULDS

56. ASPERGILLUS SPECIES
• Sources of Aspergillus spores in the hospital air:
– Inadequate filtration of outside air or
malfunctionning of ventilation
– Dust and places infrequently cleaned
– Vacuum cleaning
– Plants, flowers, etc.
– Periods of hospital constructions, renovations,
demolition 56
No uniform definition of nosocomial aspergillosis till now,
due to unknown incubation period of invasive aspergillosis
Working definition: invasive disease occurs after 1 week of
Hospitalization or within 2 weeks of hospital discharge

57. Common Aspergillus spp.causes nosocomial infection
Aspergillus fumigatus
Aspergillus flavus
Aspergillus terreusAspergillus nidulans

58. Predisposing host factors
• autologous bone
marrow transplants
• graft versus host
disease
• solid organ transplants
• Acute leukemia,
myelodyaplastic
syndrome, aplastic
anaemia
• Advanced AIDS
(reduced CD4 cell count
< 100)
• Chronic granulomatous
disease
• Pre-existing structural
lung diseases
(emphysema, COPD,
cavitory tuberculosis)
Immunosuppressive therapy
Defective NADPH oxidase
Co-existing diabetes, malnutrition,
Steroid therapy
Severe long term
granulocytopenia.
Chemotherapy &
underlying
hematologic disease
1,000/mm3

59. Clinical Diseases
• Predominately (77%)respiratory and includes
necrotizing bronchopneumonia
• Postcardiac surgery endocarditis
• Surgical site Infection (5%): Burn
wound, aortic graft sites, peritoneal catheter
sites (use of dressings contaminated with
spores)
• Cutaneous infections associated with the use
of arm boards for patients with iv catheters

60. Pathophysiology of aspergillosis
2.5–3.0 um

61. Diagnosis
• Chest radiograph: single or multiple rounded
densities
• Histopathology: tissue invasion by fungal hyphae in
skin or lung biopsy specimens confirm diagnosis.
• Culture from bronchoalveolar lavage, sputum, or
endotracheal aspirates: may represent colonization,
but in conjunction with a clinical diagnosis, positive
cultures probably indicate pulmonary aspergillosis
• Blood cultures are very insensitive for detecting
Aspergillus spp.
• Role of routine surveillance cultures of
immunocompromised patients has not been well
established.

62. • Rapid Antigen detection:
 Galactomannan, Cell-wall polysaccharide
specific to Aspergillus species, correlate with
clinical diagnosis and response to antifungal
therapy.
 Immune complexes dissociation(Heat, Acid,
Alkali) and use of monoclonal antibodies
increases sensitivity
 A sandwich ELISA, most sensitive methods
currently available to detect galactomannan
(0.5 to 1.0 ng per ml of serum).

63. Management:
• Until recently Ampho B considered gold standard
drug for invasive pulmonary aspergillosis.
• Now Voriconazole is used as 1st line therapy
(ASM & I D S A g u i d e l i n e s)
• Empirical antifungal therapy:
 with AMB, itra, vori, or caspofungin
 recommended for high-risk patients with
prolonged neutropenia who remain persistently
febrile despite broad-spectrum antibiotic therapy.
 not for patients, have short durations of
neutropenia (<10 days)

64. PREVENTION AND CONTROL
• CDC has published revised recommendations for preventing nosocomial
pulmonary aspergillosis
• Interrupt Transmission of Aspergillus sp. Spores:
1) maintenance of
a) HEPA filtration (99.97% efficient in filtering particles >0.3um),
b) directed room airflow,
c) positive air pressure in patients' rooms relative to the air pressure in
the corridor,
d) properly sealed rooms, and
e) high rates of room-air changes (100-400/hr)
2) Minimize exposures of high-risk patients to potential sources of
Aspergillus sp. (e.g., hospital construction and renovation, cleaning
activities, carpets, food, potted plants, and flower arrangements)
3) Collect environmental samples from potential sources.

66. Mucormycotina
Recent rising incidence due to continued rise of diabetics, increased use
of immunosuppressive agents and Voriconazole a broadspectrum
antifungal as prophylaxis

67. Epidemiology
Developed countries
• the disease is still a rare
finding
• mostly seen in patients with
• haematological
malignancies undergoing
chemotherapy,
• in bone marrow transplant
recipients,
• in patients receiving
voriconazole therapy or
prophylaxis.
Developing countries
• Increasing number of
mucormycosis cases
• occurring commonly in
patients with uncontrolled
diabetes
• Cases are also seen in
patients with haematological
malignancies or in transplant
recipients
In India, more than 30 million poorly compliant
diabetics, at risk of developing opportunistic
mucormycosis

68. • Modes of infection:
1) Aerosolization of the spores > tissue invasion via the
respiratory tract (in most patients).
2) acquisition is through disrupted skin(trauma and burn)
3) Ingestion of contaminated foodstuffs
• Risk factors :
1) poorly controlled diabetes mellitus,
2) Hematologic malignancies (especially with neutropenia),
3) solid-organ or hematopoietic stem cell transplant (HSCT),
4) Deferoxamine therapy for iron or aluminum overload
5) burn wounds
6) corticosteroid therapy.
• The most dramatic presentations are in patients with
diabetic ketoacidosis, tend to have rhinocerebral
(rather than pulmonary) mucormycosis.

69. Epidemiology

70. • Poor infection control practices associated with
injury mode of entry of mucormycetes in hospital.
• Interestingly from India many cases of cutaneous
mucormycosis were reported at the site of
intramuscular injection
• Very disturbing and indicates poor medical care
practices in developing countries.
• It may be gradual and slowly progressive or may be
aggressive and fulminant leading to necrotizing
lesions and haematogenous dissemination.
• Outbreak of gastrointestinal zygomycosis due to
contaminated food and drugs or even tongue
depressor.

71. • Patients with a dual mycotic infection, i.e.
Aspergilllus and a mucormycete, are not
uncommon.
• Rhizopus oryzae is commonest
• Apophysomyces and Saksenaea can initiate
invasive disease in apparently normal hosts who
have sustained penetrating trauma during
accidents.
• After the tsunami disaster in 2004, victims were
found to be infected with Apophysomyces in Sri
Lanka and Thailand

72. • The biopsy specimen should be taken from the
centre of the lesion especially from black eschar
area and include subcutaneous fat, as frequently
invade blood vessels of the dermis and subcutis.
Irregular, broad, ribbon-like,
(6-50 microns in width)
Hyphae, usually devoid of
septae,
to invade blood vessels

73. Rapidly grownon agar in gray-white, brown cottony
or wooly colonies
Sporangiophores may be septate
Columella and rhizoids, shape of the apophysis
important in genus identification

74. Apophysomyces elegans:
• is an emerging zygomycete in India
distinctive funnel- or bell-shaped apophyses, hemispherical-shaped columellae,
a conspicuous pigmented sub-apical thickening which constricts the lumen of
sporangiophore below the apophysis, and distinctive foot cells.

75. Saksenaea vasiformis
flask-shaped Sporangia with a distinct
spherical venter and long-neck, darkly
pigmented rhizoids. Sporangiospores
discharged through the neck following
the dissolution of an apical mucilaginous
plug.
•Sporulate rarely on routine media
•Difficult to differentiate from
Apophysomyces

76. • A special nutrient deficient growth medium (Czapek Dox agar,
cornmeal-glucose-sucrose-yeast extract agar), high
temperature and prolonged incubation may be used to induce
sporulation.
•By using the agar block method
described by Ellis and Ajello
(1982).
a small block of agar is cut from a
well established culture grown
on PDA and is placed in the
centre of petri dish containing
1% distilled water agar.
After 21 days at 26°C look for
sporangium formation at the
periphery of the petri dish.

77. Management
• Rapid diagnosis: Diagnosis at the early stage is desirable as the mortality 83-
94% in disseminated disease.
• Remove or reduce risk factors:
• rectifying diabetic ketoacidosis,
• withdrawing desferrioxamine therapy
• reducing the level of immunosuppression.
• Antifungal therapy and surgical debridement:
• Till date Amphotericin B is the only drug effective.
• Posaconazole as a substitute gaining popularity in recent years
• fluconazole, voriconazole, flucytosine and the echinocandins have no
efficacy.
• The best management for cutaneous zygomycosis is extensive surgical
debridement combined with antifungal.
• Adjunctive therapies: hyperbaric oxygen (HBO) treatment

78. Bundled Interventions" to Prevent Common Health Care–
Associated Infections
• Prevention of Surgical-Site
Infections:
• Choose a surgeon wisely.
• Administer prophylactic antibiotics
within 1 h before surgery; discontinue
within 24 h.
• Limit any hair removal to the time of
surgery; use clippers or do not remove
hair at all.
• Prepare surgical site with chlorhexidine-
alcohol.
• Maintain normal perioperative glucose
levels (cardiac surgery patients).
• Maintain perioperative normothermia
(colorectal surgery patients).

79. Fusarium species:
• Disseminated infections
among severely
immunocompromised
patients
• Postoperative
endophthalmitis and
peritonitis associated with
continuous ambulatory
peritoneal dialysis (CAPD)
• Local invasive infection of
wound, burn, ulcer.
• Diagnosis is usually made by
culture of biopsy specimens
or other normally sterile sites.
Hyaline, 2- to several-celled, fusiform- to
sickle-shaped macroconidia, with an
elongated apical cell and pedicellate basal
cell

80. Clinical manifestations similar with disseminated aspergillosis
except
• Associated with concomitant cellulitis or subcutaneous lesions
• More readily isolated from cultures of blood than are Aspergillus spp.
• Resistance to Amphotericin B leads to treatment and prevention failure

81. Clinical manifestations similar with disseminated aspergillosis,
except
• Associated with concomitant cellulitis or subcutaneous lesions
• More readily isolated from cultures of blood than are Aspergillus spp.
• Resistance to Amphotericin B leads to treatment and prevention failure
Microscopically similar fungal species
Cylindrocapron: Chlamydospore +ve Acremonium: microconidia in early stage of
culture

82. Management:
• Recovery from underlying neutropenia is main stay
of treatment.
• Voriconazole and Posaconazole effective.
• Combination of caspofungin with amphotericin B
showed synergistic to additive effect.

83. Acremonium species: A. kiliense, A. strictum
•Endophthalmitis following cataract surgery as colonize soft contact lenses
long awl-shaped phialides producing cylindrical,
one-celled conidia, mostly aggregated in slimy
heads at the apex of each phialide
•Rarely disseminated infections in immunosuppressed patients
Fluconazole was shown to be
completely inactive against
Acremonium in vitro
•Recurrent cutaneous infection in renal transplant cases
Drug of choice is Ampho B

84. Paecilomyces lilacinus
• Associated with intrinsic contamination of a
neutralizing solution for synthetic intraocular
lenses, resulting postoperative endophthalmitis

85. Scedosporium prolificans:
• Outbreaks reported in patients with leukemia undergoing
chemotherapy (anti-TNFα )
• Scedosporium is generally resistant to all available antifungal agents.
• Infection associated with nearly 100% mortality
• A Case of Scedosporium Prolificans Osteomyelitis in a Child reported
from our department, Misdiagnosed as Tubercular Osteomyelitis
single-celled, clavate to ovoid conidia,
borne singly or in small groups on elongate
conidiophores or laterally on hyphae

86. Pseudallescheria boydii
• An ascomycete (anamorphs are Scedosporium
apiospermum and Graphium)
• corneal ulcers, endophthalmitis, otitis externa,
sinusitis, pneumonia, and many invasive
infections in immunocompromised hosts
• commonly resistant to amphotericin B but
susceptible to miconazole and newer azoles

87. Phaeoid/ Dematiaceous/ Melanized fungi
• dark pigmentation due to presence of
dihydroxynaphthalene melanin in their cell
walls
• Ubiquitous saprobes, often considered
contaminants
• Curvularia spp, isolated from saline-filled
breast implants, resulting from contamination
of saline stored beneath a water-damaged
ceiling.
• Cladophialophora bantiana causes cerebral
pheohyphomycosis

88. • Exserohilum dermatitidis, recently causes fatal
meningitis outbreak after use of contaminated
injection
•closely resemles Bipolaris
•strongly protruding truncate hilum
(i.e. exserted hilum)

89. Pneumocystis jiroveci
• Recent reports of possible person-to-person
airborne transmission of infection suggested by
PCR testing.
• Close contacts of HIV+ patients with
Pneumocystis pneumonia, including HCWs
• Outbreaks particularly among renal transplant
recipients
• But specific isolation of hospitalized patients with
Pneumocystis pneumonia still not recommend.
• For Prevention: trimethoprim-sulfamethoxazole
prophylaxis is recommended for HSCT and SOT
recipients especially the first 100 days after
transplantation.

90. Isavuconazole
• a new and promising antifungal triazole for
the treatment of invasive fungal infections
• currently in Phase III clinical trial

91. Stop nosocomial
infections
isolation
sterilization
Tell your
doctor
everything
Ask
questions
Get
involved
apron
gloves
Hand
washing