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Refinements of Environmental Assessment During an Outbreak Investigation of Invasive Aspergillosis in a Leukemia and Bone Marrow Transplant Unit

Published online by Cambridge University Press:  02 January 2015

Chloe L. Thio ,
Dottie Smith ,
William G. Merz ,
Andrew J. Streifel ,
Greg Bova ,
Lora Gay ,
Carole B. Miller  and
Trish M. Perl
Chloe L. Thio*
Affiliation:
Division of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, Maryland
Dottie Smith
Affiliation:
Department of Hospital Epidemiology and Infection Control, Johns Hopkins School of Medicine, Baltimore, Maryland
William G. Merz
Affiliation:
Division of Microbiology, Johns Hopkins School of Medicine, Baltimore, Maryland
Andrew J. Streifel
Affiliation:
School of Public Health, University of Minnesota, Minneapolis, Minnesota
Greg Bova
Affiliation:
Facilities Engineering, Johns Hopkins School of Medicine, Baltimore, Maryland
Lora Gay
Affiliation:
Division of Microbiology, Johns Hopkins School of Medicine, Baltimore, Maryland
Carole B. Miller
Affiliation:
Department of Oncology, Johns Hopkins School of Medicine, Baltimore, Maryland
Trish M. Perl
Affiliation:
Department of Hospital Epidemiology and Infection Control, Johns Hopkins School of Medicine, Baltimore, Maryland
*
Johns Hopkins University, Division of Infectious Diseases, Ross Room 1156, 720 Rutland Ave, Baltimore, MD 21205
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Abstract

Objectives:

To investigate an outbreak of aspergillosis in a leukemia and bone marrow transplant (BMT) unit and to improve environmental assessment strategies to detect Aspergillus.

Design:

Epidemiological investigation and detailed environmental assessment.

Setting:

A tertiary-care university hospital with a 37-bed leukemia and BMT unit.

Participants:

Leukemic or BMT patients with invasive aspergillosis identified through prospective surveillance and confirmed by chart review.

Interventions:

We verified the diagnosis of invasive fungal infection by reviewing medical charts of at-risk patients, performing a case-control study to determine risk factors for infection, instituting wet mopping to clean all floors, providing N95 masks to protect patients outside high-efficiency particulate air (HEPA)-filtered areas, altering traffic patterns into the unit, and performing molecular typing of selected Aspergillus flavus isolates. To assess the environment, we verified pressure relationships between the rooms and hallway and between buildings, and we compared the ability of large-volume (1,200 L) and small-volume (160 L) air samplers to detect Aspergillus spores.

Results:

Of 29 potential invasive aspergillosis cases, 21 were confirmed by medical chart review. Risk factors for developing invasive aspergillosis included the length of time since malignancy was diagnosed (odds ratio [OR], 1.0; P=.05) and hospitalization in a patient room located near a stairwell door (OR, 3.7; P=.05). Two of five A flavus patient isolates were identical to one of the environmental isolates. The pressure in most of the rooms was higher than in the corridors, but the pressure in the oncology unit was negative with respect to the physically adjacent hospital; consequently, the unit acted essentially as a vacuum that siphoned non-HEPA-filtered air from the main hospital. Of the 78 samples obtained with a small-volume air sampler, none grew an Aspergillus species, whereas 10 of 40 cultures obtained with a large-volume air sampler did.

Conclusions:

During active construction, Aspergillus spores may have entered the oncology unit from the physically adjacent hospital because the air pressure differed. Guidelines that establish the minimum acceptable pressures and specify which pressure relationships to test in healthcare settings are needed. Our data show that large-volume air samples are superior to small-volume samples to assess for Aspergillus in the healthcare environment.

Type
Original Articles
Information
Infection Control & Hospital Epidemiology , Volume 21 , Issue 1 , January 2000 , pp. 18 - 23
Copyright
Copyright © The Society for Healthcare Epidemiology of America 2000

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