title: Outbreak of bloodstream infection with the mold Phialemonium among patients receiving dialysis at a hemodialysis unit.
abstract: BACKGROUND
  Molds are a rare cause of disseminated infection among dialysis patients.
  
  
  OBJECTIVE
  We evaluated a cluster of intravascular infections with the mold Phialemonium among patients receiving hemodialysis at the same facility in order to identify possible environmental sources and prevent further infection.
  
  
  METHODS
  Environmental assessment and case-control study.
  
  
  METHODS
  A hemodialysis center affiliated with a tertiary care hospital.
  
  
  METHODS
  We reviewed surveillance and clinical microbiology records and performed a blood culture survey for all patients. The following data for case patients were compared with those for control patients: underlying illness, dialysis characteristics, medications, and other possible exposure for 120 days prior to infection. Environmental assessment of water treatment, dialysis facilities, and heating, ventilation, and air-conditioning (HVAC) systems of the current and previous locations of the dialysis center was performed. Samples were cultured for fungus; Phialemonium isolates were confirmed by sequencing of DNA. Investigators observed dialysis access site disinfection technique.
  
  
  RESULTS
  Four patients were confirmed as case patients, defined as a patient having intravascular infection with Phialemonium species; 3 presented with fungemia, and 1 presented with an intravascular graft infection. All case patients used a fistula or graft for dialysis access, as did 12 (75%) of 16 of control patients (P=.54). Case and control patients did not differ in other dialysis characteristics, medications received, physiologic findings, or demographic factors. Phialemonium species were not recovered from samples of water or dialysis machines, but were recovered from the condensation drip pans under the blowers of the HVAC system that supplied air to the dialysis center. Observational study of 21 patients detected suboptimal contact time with antiseptic agents used to prepare dialysis access sites.
  
  
  CONCLUSIONS
  The report of this outbreak adds to previous published reports of Phialemonium infection occurring in immunocompromised patients who likely acquired infection in the healthcare setting. Recovery of this mold from blood culture should be considered indicative of infection until proven otherwise. Furthermore, an investigation into possible healthcare-related environmental reservoirs should be considered.
authors.affiliation: Epidemic Intelligence Service, Office of Workforce and Career Development, Atlanta, GA, USA.
authors.forename: Thomas
authors.initials: T
authors.lastname: Clark
authors.forename: Gregory D
authors.initials: GD
authors.lastname: Huhn
authors.forename: Craig
authors.initials: C
authors.lastname: Conover
authors.forename: Salvatore
authors.initials: S
authors.lastname: Cali
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Arduino
authors.forename: Rana
authors.initials: R
authors.lastname: Hajjeh
authors.forename: Mary E
authors.initials: ME
authors.lastname: Brandt
authors.forename: Scott K
authors.initials: SK
authors.lastname: Fridkin
mesh_terms: D000328:Adult; D000368:Aged; D000389:Air Conditioning; D001203:Ascomycota / Q000145:classification / Q000302:isolation & purification*; D001769:Blood / Q000382:microbiology; D016022:Case-Control Studies; D003470:Culture Media; D004196:Disease Outbreaks; D004696:Endocarditis / Q000453:epidemiology / Q000382:microbiology / Q000401:mortality; D005260:Female; D016469:Fungemia / Q000453:epidemiology* / Q000382:microbiology / Q000401:mortality; D006436:Hemodialysis Units, Hospital; D006801:Humans; D017053:Infection Control / Q000379:methods; D008297:Male; D008875:Middle Aged; D009181:Mycoses / Q000453:epidemiology / Q000382:microbiology / Q000401:mortality; D011159:Population Surveillance / Q000379:methods; D006435:Renal Dialysis / Q000009:adverse effects*; D014691:Ventilation; D014871:Water Microbiology
chemical_list: D003470:Culture Media