Prevention of Systemic Mycoses by Reducing Exposure to Fungal Pathogens in Hospitalized and Ambulatory Neutropenic Patients

Constance M. Smith

Sarah H. Kagan
ONF 2005, 32(3), 565-579. DOI: 10.1188/05.ONF.565-579

Purpose/Objectives: To describe sources of fungal contamination that can incite invasive mycoses in hospitalized and ambulatory neutropenic patients and to discuss approaches to reduce exposure to pathogens.

Data Sources: Published articles, books, and brochures.

Data Synthesis: Modifications of patient environments and lifestyles include hand hygiene for patients and healthcare workers, air filtration in hospitals, and reduction in exposure to plants, soil, standing water, and dusty environments. The effectiveness of dietary restrictions is controversial, although avoidance of pepper is recommended. These restrictions should be implemented prior to, during, and following neutropenia.

Conclusions: Mycoses can be hospital or community acquired; however, although guidelines for environmental and lifestyle modifications are well documented for the institutional setting, they are more limited for ambulatory patients.

Implications for Nursing: Nurses have a key role in the early identification of outbreaks of fungal infections, evaluation of hospital and home environments for sources of pathogens, education of patients on preventive measures, and research on neutropenic diets and improved technology to reduce exposure to fungal pathogens.

Jump to a section

    References

    Alberti, C., Bouakline, A., Ribaud, P., Lacroix, C., Rousselot, P., Leblanc, T., et al. (2001). Relationship between environmental fungal contamination and the incidence of invasive aspergillosis in haematology patients. Journal of Hospital Infection, 48, 198-206.

    Anaissie, E.J., Kuchar, R.T., Rex, J.H., Francesconi, A., Kasai, M., Muller, F.M., et al. (2001). Fusariosis associated with pathogenic Fusarium species colonization of a hospital water system: A new paradigm for the epidemiology of opportunistic mold infections. Clinical Infectious Diseases, 33, 1871-1878.

    Anaissie, E.J., Stratton, S.L., Dignani, M.C., Lee, C.K., Mahfouz, T.H., Rex, J.H., et al. (2002). Cleaning patient shower facilities: A novel approach to reducing patient exposure to aerosolized Aspergillus species and other opportunistic molds. Clinical Infectious Diseases, 35, E86-E88.

    Anaissie, E.J., Stratton, S.L., Dignani, M.C., Lee, C.K., Summerbell, R.C., Rex, J.H., et al. (2003). Pathogenic molds (including Aspergillus species) in hospital water distribution systems: A 3-year prospective study and clinical implications for patients with hematologic malignancies. Blood, 101, 2542-2546.

    Anaissie, E.J., Stratton, S.L., Dignani, M.C., Summerbell, R.C., Rex, J.H., Monson, T.P., et al. (2002). Pathogenic Aspergillus species recovered from a hospital water system: A 3-year prospective study. Clinical Infectious Diseases, 34, 780-789.

    Angulo, F.J., Glaser, C.A., Juranek, D.D., Lappin, M.R., & Regnery, R.L. (1994). Caring for pets of immunocompromised persons. Journal of the American Veterinary Medical Association, 205, 1711-1718.

    Bart-Delabesse, E., Cordonnier, C., & Bretagne, S. (1999). Usefulness of genotyping with microsatellite markers to investigate hospital-acquired invasive aspergillosis. Journal of Hospital Infection, 42, 321-327.

    Bodey, G.P. (1997). Fungal infection in neutropenic patients: Past achievements and future problems. In J.A. Klastersky (Ed.), Febrile neutropenia (pp. 89-98). New York: Springer.

    Bouakline, A., Lacroix, C., Roux, N., Gangneux, J.P., & Derouin, F. (2000). Fungal contamination of food in hematology units. Journal of Clinical Microbiology, 38, 4272-4273.

    Boutati, E.I., & Anaissie, E.J. (1997). Fusarium, a significant emerging pathogen in patients with hematologic malignancy: Ten years' experience at a cancer center and implications for management. Blood, 90, 999-1008.

    Bow, E.J. (1998). Invasive fungal infections in patients receiving intensive cytotoxic therapy for cancer. British Journal of Haematology, 101(Suppl. 1), S1-S4.

    Burgess, L.W. (1981). General ecology of the Fusaria. In P.E. Nelson, T.A. Toussoun, & R.J. Cook (Eds.), Fusarium: Diseases, biology, and taxonomy (pp. 225-235). University Park, PA: Pennsylvania State University Press.

    Burwen, D.R., Lasker, B.A., Rao, N., Durry, E., Padhye, A.A., & Jarvis, W.R. (2001). Invasive aspergillosis outbreak on a hematology-oncology ward. Infection Control and Hospital Epidemiology, 22, 45-48.

    Centers for Disease Control and Prevention, Infectious Disease Society of America, and American Society of Blood and Marrow Transplantation. (2000). Guidelines for preventing opportunistic infections among hematopoietic stem cell transplant recipients: Recommendations of CDC. Morbidity and Mortality Weekly Report, 49(No. RR-10), 1-128. Retrieved June 12, 2004, from http://www.cdc.gov/mmwr/preview/mmwrhtml/rr4910a1.htm

    Coopersmith, C.M., Rebmann, T.L., Zack, J.E., Ward, M.R., Corcoran, R.M., Schallom, M.E., et al. (2002). Effect of an education program on decreasing catheter-related bloodstream infections in the surgical intensive care unit. Critical Care Medicine, 30, 59-64.

    Denning, D.W. (1998). Invasive aspergillosis. Clinical Infectious Diseases, 26, 781-805.

    Faure, O., Fricker-Hidalgo, H., Lebeau, B., Mallaret, M.R., Ambroise-Thomas, P., & Grillot, R. (2002). Eight-year surveillance of environmental fungal contamination in hospital operating rooms and haematological units. Journal of Hospital Infection, 50, 155-160.

    Feld, R. (1997). Quality of life in patients with febrile neutropenia. In J.A. Klastersky (Ed.), Febrile neutropenia (pp. 117-123). New York: Springer.

    Fidel, P.L., Jr., Vazquez, J.A., & Sobel, J.D. (1999). Candida glabrata: Review of epidemiology, pathogenesis, and clinical disease with comparison to C. albicans. Clinical Microbiology Reviews, 12, 80-96.

    Fleming, R.V., Walsh, T.J., & Anaissie, E.J. (2002). Emerging and less common fungal pathogens. Infectious Disease Clinics of North America, 16, 915-933.

    Fridkin, S.K., & Jarvis, W.R. (1996). Epidemiology of nosocomial fungal infections. Clinical Microbiology Reviews, 9, 499-511.

    Gangneux, J.P., Bretagne, S., Cordonnier, C., Datry, A., Derouin, F., Grillot, R., et al. (2002). Prevention of nosocomial fungal infection: The French approach. Clinical Infectious Diseases, 35, 343-346.

    Gerson, S.L., Parker, P., Jacobs, M.R., Creger, R., & Lazarus, H.M. (1994). Aspergillosis due to carpet contamination. Infection Control and Hospital Epidemiology, 15, 221-223.

    Gudlaugsson, O., Gillespie, S., Lee, K., Vande Berg, J., Hu, J., Messer, S., et al. (2003). Attributable mortality of nosocomial candidemia, revisited. Clinical Infectious Diseases, 37, 1172-1177.

    Guiot, H.F., Fibbe, W.E., & van't Wout, J.W. (1994). Risk factors for fungal infection in patients with malignant hematologic disorders: Implications for empirical therapy and prophylaxis. Clinical Infectious Diseases, 18, 525-532.

    Hahn, T., Cummings, M., Michalek, A.M., Lipman, B.J., Segal, B.H., & McCarthy, P.L., Jr. (2002). Efficacy of high-efficiency particulate air filtration in preventing aspergillosis in immunocompromised patients with hematologic malignancies. Infection Control and Hospital Epidemiology, 23, 525-531.

    Herrmann, R.P., Trent, M., Cooney, J., & Cannell, P.K. (1999). Infections in patients managed at home during autologous stem cell transplantation for lymphoma and multiple myeloma. Bone Marrow Transplantation, 24, 1213-1217.

    Hobson, R.P. (2003). The global epidemiology of invasive Candida infections—Is the tide turning? Journal of Hospital Infection, 55, 159-168.

    Humphreys, H. (2004). Positive-pressure isolation and the prevention of invasive aspergillosis. What is the evidence? Journal of Hospital Infection, 56, 93-100.

    Jantunen, E., Ruutu, P., Niskanen, L., Volin, L., Parkkali, T., Koukila-Kahkola, P., et al. (1997). Incidence and risk factors for invasive fungal infections in allogeneic BMT recipients. Bone Marrow Transplantation, 19, 801-808.

    Johnson, E., Gilmore, M., Newman, J., & Stephens, M. (2000). Preventing fungal infections in immunocompromised patients. British Journal of Nursing, 9, 1154, 1156, 1158-1164.

    Kuderer, N.M., Cosler, L., Crawford, J., Dale, D.C., & Lyman, G.H. (2002). Cost and mortality associated with febrile neutropenia in adult cancer patients [Abstract 998]. Proceedings of the American Society of Clinical Oncology, 21, 250a.

    Lass-Florl, C., Rath, P., Niederwieser, D., Kofler, G., Wurzner, R., Krezy, A., et al. (2000). Aspergillus terreus infections in haematological malignancies: Molecular epidemiology suggests association with in-hospital plants. Journal of Hospital Infection, 46, 31-35.

    Lass-Florl, C., Salzer, G.M., Schmid, T., Rabl, W., Ulmer, H., & Dierichi, M. (1999). Pulmonary Aspergillus colonization in humans and its impact on management of critically ill patients. British Journal of Haematology, 104, 745-747.

    Latge, J.P. (1999). Aspergillus fumigatus and aspergillosis. Clinical Microbiology Reviews, 12, 310-350.

    Loudon, K.W., Coke, A.P., Burnie, J.P., Shaw, A.J., Oppenheim, B.A., & Morris, C.Q. (1996). Kitchens as a source of Aspergillus niger infection. Journal of Hospital Infection, 32, 191-198.

    Lueg, E.A., Ballagh, R.H., & Forte, V. (1996). Analysis of the recent cluster of invasive fungal sinusitis at the Toronto Hospital for Sick Children. Journal of Otolaryngology, 25, 366-370.

    Lyman, G.H., & Kuderer, N.M. (1997). Incorporation of quality-of-life considerations into decision models for the use of colony-stimulating factors in chemotherapy patients at risk for febrile neutropenia. In J. A. Klastersky (Ed.), Febrile neutropenia (pp. 17-22). New York: Springer.

    Manuel, R.J., & Kibbler, C.C. (1998). The epidemiology and prevention of invasive aspergillosis. Journal of Hospital Infection, 39, 95-109.

    Marr, K.A., Carter, R.A., Boeckh, M., Martin, P., & Corey, L. (2002). Invasive aspergillosis in allogeneic stem cell transplant recipients: Changes in epidemiology and risk factors. Blood, 100, 4358-4366.

    Marr, K.A., Carter, R.A., Crippa, F., Wald, A., & Corey, L. (2002). Epidemiology and outcome of mould infections in hematopoietic stem cell transplant recipients. Clinical Infectious Diseases, 34, 909-917.

    Martino, P., Girmenia, C., Venditti, M., Micozzi, A., Santilli, S., Burgio, V.L., et al. (1989). Candida colonization and systemic infection in neutropenic patients: A retrospective study. Cancer, 64, 2030-2034.

    McKee, L.H. (1995). Microbial contamination of spices and herbs: A review. Lebensmittel-Wissenschaft und Technologie, 28, 1-11.

    Meunier, F. (1987). Prevention of mycoses in immunocompromised patients. Reviews of Infectious Diseases, 9, 408-416.

    Morris, G., Kokki, M.H., Anderson, K., & Richardson, M.D. (2000). Sampling of Aspergillus spores in air. Journal of Hospital Infection, 44, 81-92.

    Nelson, P.E., Dignani, M.C., & Anaissie, E.J. (1994). Taxonomy, biology, and clinical aspects of Fusarium species. Clinical Microbiology Reviews, 7, 479-504.

    Nucci, M., & Anaissie, E. (2002). Cutaneous infection by Fusarium species in healthy and immunocompromised hosts: Implications for diagnosis and management. Clinical Infectious Diseases, 35, 909-920.

    Nucci, M., Marr, K.A., Queiroz-Telles, F., Martins, C.A., Trabasso, P., Costa, S., et al. (2004). Fusarium infection in hematopoietic stem cell transplant recipients. Clinical Infectious Diseases, 38, 1237-1242.

    Orth, B., Frei, R., Itin, P.H., Rinaldi, M.G., Speck, B., Gratwohl, A., et al. (1996). Outbreak of invasive mycoses caused by Paecilomyces lilacinus from a contaminated skin lotion. Annals of Internal Medicine, 125, 799-806.

    Pagano, L., Antinori, A., Ammassari, A., Mele, L., Nosari, A., Melillo, L., et al. (1999). Retrospective study of candidemia in patients with hematological malignancies. Clinical features, risk factors and outcome of 76 episodes. European Journal of Haematology, 63, 77-85.

    Patterson, J.E., Zidouh, A., Miniter, P., Andriole, V.T., & Patterson, T.F. (1997). Hospital epidemiologic surveillance for invasive aspergillosis: Patient demographics and the utility of antigen detection. Infection Control and Hospital Epidemiology, 18, 104-108.

    Pfaller, M.A. (1996). Nosocomial candidiasis: Emerging species, reservoirs, and modes of transmission. Clinical Infectious Diseases, 22(Suppl. 2), S89-S94.

    Philpott-Howard, J. (1996). Prevention of fungal infections in hematology patients. Infection Control and Hospital Epidemiology, 17, 545-551.

    Pittet, D., Mourouga, P., & Perneger, T.V. (1999). Compliance with handwashing in a teaching hospital. Annals of Internal Medicine, 130, 126-130.

    Price, E.H., Jones, R., Groombridge, S., & Hoffman, P.N. (2002). Risk to immune suppressed patients from Aspergillus spp. growing in fridge condensate trays. Journal of Hospital Infection, 52, 72.

    Raad, I., Hanna, H., Osting, C., Hachem, R., Umphrey J., Tarrand, J., et al. (2002). Masking of neutropenic patients on transport from hospital rooms is associated with a decrease in nosocomial aspergillosis during construction. Infection Control and Hospital Epidemiology, 23, 41-43.

    Raad, I., Tarrand, J., Hanna, H., Albitar, M., Janssen, E., Boktour, M., et al. (2002). Epidemiology, molecular mycology, and environmental sources of Fusarium infection in patients with cancer. Infection Control and Hospital Epidemiology, 23, 532-537.

    Reagan, D.R., Pfaller, M.A., Hollis, R.J., & Wenzel, R.P. (1990). Characterization of the sequence of colonization and nosocomial candidemia using DNA fingerprinting and a DNA probe. Journal of Clinical Microbiology, 28, 2733-2738.

    Rhame, F.S. (1991). Prevention of nosocomial aspergillosis. Journal of Hospital Infection, 18(Suppl. A), 466-472.

    Ribes, J.A., Vanover-Sams, C.L., & Baker, D.J. (2000). Zygomycetes in human disease. Clinical Microbiology Reviews, 13, 236-301.

    Richard-Smith, A., & Buh, S. (1995). Reducing central line catheter infections in bone marrow transplant patients. Nursing Clinics of North America, 30, 45-52.

    Risi, G.F., & Tomascak, V. (1998). Prevention of infection in the immunocompromised host. American Journal of Infection Control, 26, 594-606.

    Rotstein, C., Bow, E.J., Laverdiere, M., Carr, D., Moghaddam, N., & Ioannou, S. (1996). A multicentre, randomized, placebo-controlled trial of fluconazole prophylaxis for fungal infection in neutropenic cancer patients [Abstract 1694]. Blood, 88(Suppl. 1), S426a.

    Segal, B.H., Bow, E.J., & Menichetti, F. (2002). Fungal infections in non-transplant patients with hematologic malignancies. Infectious Disease Clinics of North America, 16, 935-964.

    Shinjo, K., Takeshita, A., Yanagi, M., Yokota, K., Hirano, K., Suzuki, M., et al. (2002). Efficacy of the Shinki bioclean room for preventing infection in neutropenic patients. Journal of Advanced Nursing, 37, 227-233.

    Smith, L.H., & Besser, S.G. (2000). Dietary restrictions for patients with neutropenia: A survey of institutional practices. Oncology Nursing Forum, 27, 515-520.

    Sporik, R.B., Arruda, L.K., Woodfolk, J., Chapman, M.D., & Platts-Mills, T.A.E. (1993). Environmental exposure to Aspergillus fumigatus allergen (Asp fI). Clinical and Experimental Allergy, 23, 326-331.

    Stoiser, B., Kofler, J., Staudinger, T., Georgopoulos, A., Lugauer, S., Guggenbichler, J.P., et al. (2002). Contamination of central venous catheters in immunocompromised patients: A comparison between two different types of central venous catheters. Journal of Hospital Infection, 50, 202-206.

    Strausbaugh, L.J., Sewell, D.L., Ward, T.T., Pfaller, M.A., Heitzman, T., & Tjoelker, R. (1994). High frequency of yeast carriage on hands of hospital personnel. Journal of Clinical Microbiology, 32, 2299-2300.

    Symoens, F., Burnod, J., Lebeau, B., Viviani, M.A., Piens, M.A., Tortorano, A.M., et al. (2002). Hospital-acquired Aspergillus fumigatus infection: Can molecular typing methods identify an environmental source? Journal of Hospital Infection, 52, 60-67.

    Thio, C.L., Smith, D., Merz, W.G., Streifel, A.J., Bova, G., Gay, L., et al. (2000). Refinements of environmental assessment during an outbreak investigation of invasive aspergillosis in a leukemia and bone marrow transplant unit. Infection Control and Hospital Epidemiology, 21, 18-23.

    Todd, J., Schmidt, M., Christain, J., & Williams, R. (1999). The low-bacteria diet for immunocompromised patients: Reasonable prudence or clinical superstition? Cancer Practice, 7, 205-207.

    Trustees of the University of Pennsylvania. (2001). What you should know about low blood counts [Brochure]. Philadelphia: Author.

    Vazquez, J.A., Dembry, L.M., Sanchez, V., Vazquez, M.A., Sobel, J.D., Dmuchowski, C., et al. (1998). Nosocomial Candida glabrata colonization: An epidemiologic study. Journal of Clinical Microbiology, 36, 421-426.

    Vazquez, J.A., Sanchez, V., Dmuchowski, C., Dembry, L.M., Sobel, J.D., & Zervos, M.J. (1993). Nosocomial acquisition of Candida albicans: An epidemiologic study. Journal of Infectious Diseases, 168, 195-201.

    Wald, A., Leisenring, W., van Burik, J., & Bowden, R.A. (1997). Epidemiology of Aspergillus infections in a large cohort of patients undergoing bone marrow transplantation. Journal of Infectious Diseases, 175, 1459-1466.

    Warnock, D.W. (1998). Fungal infections in neutropenia: Current problems and chemotherapeutic control. Journal of Antimicrobial Chemotherapy, 41(Suppl. D), 95-105.

    Withington, S., Chambers, S.T., Beard, M.E., Inder, A., Allen, J.R., Ikram, R.B., et al. (1998). Invasive aspergillosis in severely neutropenic patients over 18 years: Impact of intranasal amphotericin B and HEPA filtration. Journal of Hospital Infection, 38, 11-18.