Fungus from the Pharmacy: An Unusual Outbreak of Nosocomial Fungemia

Abstract & Commentary

Synopsis: An outbreak of fungemia in compromised hosts due to E jeanselmei, a dematiaceous fungus, was traced to deionized water used to compound antiseptic solutions in a hospital pharmacy.

Source: Nucci M, et al. Nosocomial outbreak of Exophiala jeanselmei fungemia associated with contamination of hospital water. Clin Infect Dis. 2002;34:1475-1480.

Over a 22-month period, 19 episodes of nosocomial fungemia due to Exophiala jeanselmei occurred among patients admitted to a university hospital in Brazil. The majority of patients were immunocompromised due to malignancy, neutropenia, corticosteroid therapy, or HIV infection. Fourteen (74%) had a central venous catheter. In a case-control study, neutropenia, duration of hospitalization, and receipt of corticosteroids were identified as independent risk factors for infection. Nucci and colleagues obtained multiple cultures of blood products, intravenous solutions, and water sources within the hospital. They isolated E jeanselmei from 3 sources: a storage tank, a sink in a nonpatient care area, and the deionizer in the pharmacy. Water processed by the latter was used to prepare skin disinfectant solutions, primarily 70% alcohol and alcohol/chlorhexidine. These solutions were routinely used for skin disinfection during venipuncture or vascular catheter care. DNA typing of clinical and environmental isolates by means of random amplification of polymorphic DNA (RAPD) showed that clinical strains and the pharmacy strain were all highly related, and unrelated to E jeanselmei isolated from other sites. Once the pharmacy deionizer was taken out of service, no further cases occurred.

Comment by Stan Deresinski, MD, FACP

E jeanselmei is a dematiaceous fungus, and members of this group of organisms are common inhabitants of soil and water. They produce melanin, which gives them their characteristic pigmentation on culture media. Its nomenclature is the subject of some disagreement; some of the other species reported in human infection include Alternaria, Dactylaria, Phialophora, and Curvularia.1 Disease in immunocompetent patients often manifests as soft tissue, bone, or joint infection after contamination of wounds with soil or water. Susceptibility to antifungal agents is variable, and debridement is a major therapeutic maneuver in these localized infections. More invasive disease occurs in immunosuppressed patients. Fungemia, invasive sinusitis, brain abscess, and pulmonary invasion are among the reported syndromes.2,3

The report of Nucci et al is notable in that a nosocomial outbreak was traced to a water source in the hospital pharmacy. Although hospital water is a well-recognized cause of nosocomial infection due to bacterial pathogens, including Legionella and nonfermentative Gram-negative bacilli, there is growing evidence that hospital water may be a source of invasive fungal infection as well. Hospital water has been implicated in nosocomial infection due to Fusarium solani4 and Aspergillus fumigatus.5 The proposed mechanism is inhalation of fungal spores aerosolized from water fixtures.

The population of patients at risk for invasive fungal infection continues to grow due to advances in transplantation, cancer treatment, and care of HIV infection. At present, the magnitude of risk posed by fungal colonization of hospital water systems remains to be elucidated. This is an area deserving serious attention by hospital epidemiologists.

Dr. Deresinski, Clinical Professor of Medicine, Stanford; Associate Chief of Infectious Diseases, Santa Clara Valley Medical Center, is Editor of Infectious Disease Alert.

References

1. Perfect JR. The new fungal opportunists are coming. Clin Infect Dis. 1996;22(Suppl 2):S112-S118.

2. Rossmann SN, et al. Dematiaceous fungi are an increasing cause of human disease. Clin Infect Dis. 1996;22:73-80.

3. Nucci M, et al. Nosocomial fungemia due to Exophiala jeansemei var. jeanselmei and a Rhinocladiella species: Newly described causes of bloodstream infection. J Clin Microbiol. 2001;39:514-518.

4. Anaissie EJ, et al. Fusariosis associated with pathogenic Fusarium species colonization of a hospital water system: A new paradigm for the epidemiology of opportunistic mold infections. Clin Infect Dis. 2001;33(11): 1871-1878.

5. Anaissie EJ, et al. Pathogenic Aspergillus spp. recovered from a hospital water system: A 3-year prospective study. Clin Infect Dis. 2002;34:780-789.

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