Nosocomial Transmission of Cryptococcosis
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《新英格兰医药杂志》
To the Editor: Human-to-human transmission of cryptococcosis is very rare.1,2,3 An 80-year-old man (Patient A) was hospitalized because of pulmonary squamous-cell carcinoma. He received mechanical ventilation and was transferred to the medical intensive care unit on July 6, 2004. A new infiltrate in the right lung and pleural effusion associated with fever developed on August 15, 2004. Cultures of the pleural effusion drawn on August 19 yielded Cryptococcus neoformans (isolate A). The patient died of refractory respiratory failure on September 19, 2004.
A 77-year-old man (Patient B) was admitted to the same medical intensive care unit on July 27, 2004, and occupied the bed next to Patient A. This patient had disseminated cryptococcal infection. C. neoformans was isolated from specimens of his blood (isolate B1), cerebrospinal fluid (isolate B2), sputum, bronchoalveolar-lavage fluid, and urine (isolate B3). Large amounts of the fungus were seen in the latter four specimens. The patient had a satisfactory response to treatment with liposomal amphotericin B. Unfortunately, he died of septic shock and multiorgan failure associated with methicillin-resistant Staphylococcus aureus bacteremia on September 14, 2004.
The minimal inhibitory concentrations of fluconazole and amphotericin B, determined with use of the E Test (AB Biodisk), were identical among isolates A, B1, B2, and B3 (0.125 mg per milliliter for fluconazole and 8 mg per milliliter for amphotericin B). Molecular typing of the four isolates and eight other isolates (control strains) by arbitrarily primed polymerase-chain-reaction analyses with the use of four random oligonucleotide primers (M13, OPH-15, OPH-19, and ERIC1) and karyotyping disclosed that the isolates from the two patients were identical and were different from the eight control strains.4,5
C. neoformans is susceptible to 1 percent sodium hypochlorite and iodine, but its susceptibility to 70 percent ethanol and ethylene oxide is questionable. The hands of medical personnel and the instruments routinely used in the respiratory intensive care unit (such as ventilators and ultrasound equipment) might be contaminated by secretions from an index patient. Patient A might have acquired the organism through direct inhalation of airborne fungus as a result of the short distance between the two beds or through a respiratory care procedure (such as sputum suction) performed with contaminated instruments by medical personnel. Unfortunately, cultures of the environment (floor, bed, ventilator surface, monitoring equipment, radiograph-viewing box, and nursing and emergency carts) one month after the notification of this event were all negative for C. neoformans.
In conclusion, we report a case of likely nosocomial spread of cryptococcosis. Strict adherence to appropriate infection-control measures is mandatory to control the spread of cryptococcosis in hospitals.
Cheng-Yi Wang, M.D.
Huey-Dong Wu, M.D.
Po-Ren Hsueh, M.D.
National Taiwan University Hospital
Taipei 100, Taiwan
hsporen@ha.mc.ntu.edu.tw
A 77-year-old man (Patient B) was admitted to the same medical intensive care unit on July 27, 2004, and occupied the bed next to Patient A. This patient had disseminated cryptococcal infection. C. neoformans was isolated from specimens of his blood (isolate B1), cerebrospinal fluid (isolate B2), sputum, bronchoalveolar-lavage fluid, and urine (isolate B3). Large amounts of the fungus were seen in the latter four specimens. The patient had a satisfactory response to treatment with liposomal amphotericin B. Unfortunately, he died of septic shock and multiorgan failure associated with methicillin-resistant Staphylococcus aureus bacteremia on September 14, 2004.
The minimal inhibitory concentrations of fluconazole and amphotericin B, determined with use of the E Test (AB Biodisk), were identical among isolates A, B1, B2, and B3 (0.125 mg per milliliter for fluconazole and 8 mg per milliliter for amphotericin B). Molecular typing of the four isolates and eight other isolates (control strains) by arbitrarily primed polymerase-chain-reaction analyses with the use of four random oligonucleotide primers (M13, OPH-15, OPH-19, and ERIC1) and karyotyping disclosed that the isolates from the two patients were identical and were different from the eight control strains.4,5
C. neoformans is susceptible to 1 percent sodium hypochlorite and iodine, but its susceptibility to 70 percent ethanol and ethylene oxide is questionable. The hands of medical personnel and the instruments routinely used in the respiratory intensive care unit (such as ventilators and ultrasound equipment) might be contaminated by secretions from an index patient. Patient A might have acquired the organism through direct inhalation of airborne fungus as a result of the short distance between the two beds or through a respiratory care procedure (such as sputum suction) performed with contaminated instruments by medical personnel. Unfortunately, cultures of the environment (floor, bed, ventilator surface, monitoring equipment, radiograph-viewing box, and nursing and emergency carts) one month after the notification of this event were all negative for C. neoformans.
In conclusion, we report a case of likely nosocomial spread of cryptococcosis. Strict adherence to appropriate infection-control measures is mandatory to control the spread of cryptococcosis in hospitals.
Cheng-Yi Wang, M.D.
Huey-Dong Wu, M.D.
Po-Ren Hsueh, M.D.
National Taiwan University Hospital
Taipei 100, Taiwan
hsporen@ha.mc.ntu.edu.tw