Hostname: page-component-586b7cd67f-rcrh6 Total loading time: 0 Render date: 2024-11-24T19:33:18.425Z Has data issue: false hasContentIssue false

Patient notification about suspected hospital-associated outbreaks of invasive mold infections: Considerations for public health and hospital personnel

Published online by Cambridge University Press:  10 June 2021

Pooja Gandhi
Affiliation:
Applied Sciences, Research and Technology, Inc., Smyrna, Georgia
Kaitlin Benedict
Affiliation:
Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
Mitsuru Toda
Affiliation:
Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
Karlyn D. Beer
Affiliation:
Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
Tom M. Chiller
Affiliation:
Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
Brendan R. Jackson*
Affiliation:
Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
*
Author for correspondence: Brendan R. Jackson, E-mail: [email protected]

Abstract

A common type of fungal disease investigation involves hospital-associated clusters of invasive mold infections (IMIs), which typically occur among immunocompromised patients. Responding to IMI clusters can be challenging for public health and hospital personnel for several reasons such as difficulty of confirming the existence of an outbreak, difficulty of determining source. Although many resources exist to guide patient notification about healthcare incidents (eg, bloodborne exposures, disease outbreaks), IMI clusters involve special considerations related to the complex diseases, uncertain exposures, and differential benefits and risks of notification. Early, nuanced communication about hospital-associated IMI clusters is almost always the best course of action to help reduce risks to patients’ health and foster trust between patients and hospitals.

Type
Commentary
Copyright
© The Author(s), 2021. Published by Cambridge University Press on behalf of The Society for Healthcare Epidemiology of America

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Kanamori, H, Rutala, WA, Sickbert-Bennett, EE, Weber, DJ. Review of fungal outbreaks and infection prevention in healthcare settings during construction and renovation. Clin Infect Dis 2015;61:433444.CrossRefGoogle ScholarPubMed
Morace, G, Borghi, E. Invasive mold infections: virulence and pathogenesis of mucorales. Int J Microbiol 2012;2012:349278349278.CrossRefGoogle ScholarPubMed
Hartnett, KP, Jackson, BR, Perkins, KM, et al. A guide to investigating suspected outbreaks of mucormycosis in healthcare. J Fungi (Basel, Switzerland) 2019;5(3):69.CrossRefGoogle Scholar
Masaphy, S, Ezra, R. Targeted inspection of environmental mycological load for mitigation of indoor mold toward improved public health. J Microb Biochem Technol 2016. doi: 10.4172/1948-5948.1000324.CrossRefGoogle Scholar
Thio, CL, Smith, D, Merz, WG, et al. Refinements of environmental assessment during an outbreak investigation of invasive aspergillosis in a leukemia and bone marrow transplant unit. Infect Control Hosp Epidemiol 2000;21:1823.CrossRefGoogle Scholar
Novosad, SA, Vasquez, AM, Nambiar, A, et al. Notes from the field: probable mucormycosis among adult solid-organ transplant recipients at an acute-care hospital—Pennsylvania, 2014–2015. Morbid Mortal Wkly Rep 2016;65:481482.CrossRefGoogle ScholarPubMed
Enoch, DA, Yang, H, Aliyu, SH, Micallef, C. The changing epidemiology of invasive fungal infections. In: Lion T, ed. Human Fungal Pathogen Identification: Methods and Protocols. New York: Springer; 2017:1765.CrossRefGoogle Scholar
Baddley, JW, Stroud, TP, Salzman, D, Pappas, PG. Invasive mold infections in allogeneic bone marrow transplant recipients. Clin Infect Dis 2001;32:13191324.CrossRefGoogle ScholarPubMed
Introduction to the patient notification toolkit. Centers for Disease Control and Prevention website. https://www.cdc.gov/injectionsafety/pntoolkit/index.html. Accessed April 21, 2021.Google Scholar
Crisis and emergency risk communication manual. Centers for Disease Control and Prevention website. https://emergency.cdc.gov/cerc/manual/index.asp. Accessed April 21, 2021.Google Scholar
Tumpey, AJ, Daigle, D, Nowak, G. The CDC field epidemiology manual: communicating during an outbreak or public investigation. Centers for Disease Control and Prevention website. https://www.cdc.gov/eis/field-epi-manual/chapters/Communicating-Investigation.html. Accessed April 21, 2021.Google Scholar
Interim framework for healthcare-associated infection outbreak notification. Council for Outbreak Response: Healthcare-Associated Infections and Antimicrobial-Resistant Pathogens website. https://corha.org/wp-content/uploads/2020/04/CORHA-Policy-HAI-Outbreak-Notification-Framework.pdf. Accessed April 21, 2021.Google Scholar
Schaefer, MK, Perkins, KM, Link-Gelles, R, Kallen, AJ, Patel, PR, Perz, JF. Outbreaks and infection control breaches in healthcare settings: considerations for patient notification. Am J Infect Control 2020;48:718724.CrossRefGoogle ScholarPubMed
Lockhart, SR, Pham, CD, Gade, L, et al. Preliminary laboratory report of fungal infections associated with contaminated methylprednisolone injections. J Clin Microbiol 2013;51:26542661.CrossRefGoogle ScholarPubMed
Vallabhaneni, S, Benedict, K, Derado, G, Mody, RK. Trends in hospitalizations related to invasive aspergillosis and mucormycosis in the United States, 2000–2013. Open Forum Infect Dis 2017;4:ofw268ofw268.CrossRefGoogle Scholar
Institute of Medicine (US) Committee on Damp Indoor Spaces and Health. Damp Indoor Spaces and Health. Washington, DC: National Academies Press 2004.Google Scholar
Benedict, K, Jackson, BR, Chiller, T, Beer, KD. Estimation of direct healthcare costs of fungal diseases in the United States. Clin Infect Dis 2019;68:17911797.CrossRefGoogle ScholarPubMed
Chow, NA, Toda, M, Pennington, AF, et al. Hurricane-associated mold exposures among patients at risk for invasive mold infections after Hurricane Harvey—Houston, Texas, 2017. Morbid Mortal Wkly Rep 2019;68:469473.CrossRefGoogle ScholarPubMed
Maschmeyer, G, Calandra, T, Singh, N, Wiley, J, Perfect, J. Invasive mould infections: a multidisciplinary update. Med Mycol 2009;47:571583.CrossRefGoogle Scholar
Taccone, FS, Van den Abeele, A-M, Bulpa, P, et al. Epidemiology of invasive aspergillosis in critically ill patients: clinical presentation, underlying conditions, and outcomes. Crit Care 2015;19:7.CrossRefGoogle ScholarPubMed
Blot, SI, Taccone, FS, Van den Abeele, AM, et al. A clinical algorithm to diagnose invasive pulmonary aspergillosis in critically ill patients. Am J Respir Crit Care Med 2012;186:5664.CrossRefGoogle ScholarPubMed
Baddley, JW, Stephens, JM, Ji, X, Gao, X, Schlamm, HT, Tarallo, M. Aspergillosis in intensive care unit (ICU) patients: epidemiology and economic outcomes. BMC Infect Dis 2013;13:29.CrossRefGoogle ScholarPubMed
Vazquez, J, Tovar-Torres, M, Hingwe, A, Cheema, F, Welch, V, Ford, K. The changing epidemiology of invasive aspergillosis in the non-traditional host: risk factors and outcomes. Pulmon Crit Care Med 2016. doi: 10.15761/PCCM.1000114.CrossRefGoogle Scholar
Patterson, TF, Thompson, GR, Denning, DW, et al. Practice guidelines for the diagnosis and management of aspergillosis: 2016 update by the Infectious Diseases Society of America. Clin Infect Dis 2016;63(4):e1e60.CrossRefGoogle ScholarPubMed
Jensen, J, Guinea, J, Torres-Narbona, M, Muñoz, P, Peláez, T, Bouza, E. Postsurgical invasive aspergillosis: an uncommon and under-appreciated entity. J Infect 2010;60:162167.CrossRefGoogle Scholar
Rammaert, B, Lanternier, F, Zahar, J-R, et al. Healthcare-associated mucormycosis. Clin Infect Dis 2012;54 suppl 1:S44S54.CrossRefGoogle Scholar
Vonberg, RP, Gastmeier, P. Nosocomial aspergillosis in outbreak settings. J Hosp Infect 2006;63:246254.CrossRefGoogle ScholarPubMed
Bartlett, AH, Garcia-Houchins, S, Marrs, R, Landon, E. Mold contamination due to construction dust in ventilation system detected during routine precommissioning air sampling. Open Forum Infect Dis 2017;4 suppl 1:S189S189.CrossRefGoogle Scholar
Oren, I, Haddad, N, Finkelstein, R, Rowe, JM. Invasive pulmonary aspergillosis in neutropenic patients during hospital construction: before and after chemoprophylaxis and institution of HEPA filters. Am J Hematol 2001;66:257262.CrossRefGoogle ScholarPubMed
Pini, G, Faggi, E, Donato, R, Sacco, C, Fanci, R. Invasive pulmonary aspergillosis in neutropenic patients and the influence of hospital renovation. Mycoses 2008;51:117122.CrossRefGoogle ScholarPubMed
Duffy, J, Harris, J, Gade, L, et al. Mucormycosis outbreak associated with hospital linens. Pediatr Infect Dis J 2014;33:472476.CrossRefGoogle ScholarPubMed
Ahearn, DG, Stulting, RD. Moulds associated with contaminated ocular and injectable drugs: FDA recalls, epidemiology considerations, drug shortages, and aseptic processing. Med Mycol 2018;56:389394.CrossRefGoogle ScholarPubMed
Sundermann, AJ, Clancy, CJ, Pasculle, AW, et al. How clean is the linen at my hospital? The mucorales on unclean linen discovery study of large United States transplant and cancer centers. Clin Infect Dis 2018;68:850853.CrossRefGoogle Scholar
Cheng, VCC, Chen, JHK, Wong, SCY, et al. Hospital outbreak of pulmonary and cutaneous zygomycosis due to contaminated linen items from substandard laundry. Clin Infect Dis 2015;62:714721.CrossRefGoogle ScholarPubMed
Lalayanni, C, Baliakas, P, Xochelli, A, et al. Outbreak of cutaneous zygomycosis associated with the use of adhesive tape in haematology patients. J Hosp Infect 2012;81:213215.CrossRefGoogle ScholarPubMed
Seattle Children’s Hospital has again shut down operating rooms due to mold problems. CNN website. https://www.cnn.com/2019/11/12/health/seattle-childrens-hospital-mold/index.html. Accessed April 21, 2021.Google Scholar
Mold at two Pittsburgh hospitals linked to 5 deaths. CNN website. https://www.cnn.com/2017/01/28/health/moldy-hospital-bed-linen-deaths/index.html. Accessed April 21, 2021.Google Scholar
Messina, JA, Wolfe, CR, Hemmersbach-Miller, M, et al. Genomic characterization of recurrent mold infections in thoracic transplant recipients. Transpl Infect Dis 2018;20(5):e12935e12935.CrossRefGoogle ScholarPubMed
Kelly, BT, Pennington, KM, Limper, AH. Advances in the diagnosis of fungal pneumonias. Expert Rev Respir Med 2020:1–12.Google Scholar
Farges, C, Cointault, O, Murris, M, et al. Outcomes of solid organ transplant recipients with invasive aspergillosis and other mold infections. Transpl Infect Dis 2020;22(1):e13200.CrossRefGoogle ScholarPubMed
Winters, B, Custer, J, Galvagno, SM Jr, et al. Diagnostic errors in the intensive care unit: a systematic review of autopsy studies. BMJ Qual Saf 2012;21:894902.CrossRefGoogle ScholarPubMed
Zika: how to communicate effectively. Centers for Disease Control and Prevention website. https://www.cdc.gov/zika/zap/pdfs/presentations/zap-how-to-communicate-effectively.pdf. Accessed April 21, 2021.Google Scholar
Prouty, CD, Foglia, MB, Gallagher, TH. Patients’ experiences with disclosure of a large-scale adverse event. J Clin Ethics 2013;24:353363.Google ScholarPubMed
Dudzinski, DM, Hébert, PC, Foglia, MB, Gallagher, TH. The disclosure dilemma—large-scale adverse events. N Engl J Med 2010;363:978986.CrossRefGoogle ScholarPubMed
Mazor, KM, Simon, SR, Yood, RA, et al. Health plan members’ views about disclosure of medical errors. Ann Intern Med 2004;140:409418.CrossRefGoogle ScholarPubMed
Catalanello, R. Children’s hospital: ‘we failed to do what we should have done.’ The Times-Picayune, April 18, 2014.Google Scholar
Gilbert, DB, Blethen, R. ‘We failed’: Seattle Children’s CEO admits 6 deaths, more illnesses due to mold in ORs. The Seattle Times, November 18, 2019.Google Scholar
Jarashow, MC, Terashita, D, Balter, S, Schwartz, B. Notes from the field: mycobacteria chimaera infections associated with heater-cooler unit use during cardiopulmonary bypass surgery—Los Angeles County, 2012–2016. Morbid Mortal Wkly Rep 2019;67:14281429.CrossRefGoogle ScholarPubMed
Davies, L, Stiff, R, Davies, E, Shankar, AG, Jenkins, S, Mason, BW. A patient notification exercise for Mycobacterium chimaera infection associated with cardiac bypass surgery: the Welsh perspective. Public Health 2017;153:6163.CrossRefGoogle ScholarPubMed
Plain Language website. https://www.plainlanguage.gov/. Accessed April 21, 2021.Google Scholar
Berkman, ND, Sheridan, SL, Donahue, KE, Halpern, DJ, Crotty, K. Low health literacy and health outcomes: an updated systematic review. Ann Intern Med 2011;155:97107.CrossRefGoogle Scholar
Seurer, AC, Vogt, HB. Low health literacy: a barrier to effective patient care. S Dak Med 2013;66:51, 5357.Google ScholarPubMed
Stableford, S, Mettger, W. Plain language: a strategic response to the health literacy challenge. J Public Health Pol 2007;28:7193.CrossRefGoogle ScholarPubMed
Supplementary material: File

Gandhi et al. supplementary material

Gandhi et al. supplementary material

Download Gandhi et al. supplementary material(File)
File 26.3 KB