Among the invasive fungal infections, zygomycosis are those whose diagnosis and prompt treatment are an immediate vital issue. Vascular tropism of these filamentous fungi is one of the major reasons for their ability to disseminate (1) . Only a few antifungals are sensitive in vitro. Treatment 1 st line based on the lipid derivatives of amphotericin B (2) , posaconazole can be used in 2 nd line (3; 4) . Other antifungal agents, such as caspofungin or voriconazole, have no activity in vitro (5) . Voriconazole, used for prophylaxis of invasive fungal infections in hematology even increase the virulence of these fungi (6-8) . It is precisely in this care sector that zygomycetes are responsible for opportunistic infections (9) . It's the same in highly immunocompromised patients such as transplantation of solid organs or bone marrow (10-12) . In diabetic patients, the prevalence of zygomycosis in France rose by 9% / year between 1997 and 2006 (13) . Zygomycetes are present in the environment, especially in soil and decomposing material (14) . Patients are contaminated by inhalation, dermal following a breach of the skin barrier, or ingestion (rarer way and that requires a strong inoculum and disrupting the gastrointestinal mucosa barrier) (14) . Their incubation period is unknown, which is a contaminated patient outside the hospital can be infected during immunosuppressive therapy while he is hospitalized. Trauma, such as accidents on public roads are also purveyors of zygomycosis when the wounds were contaminated with organic material (15) . However, if we look closely to the care proceedings, whether performed in hospitals or ambulatory, there is a potential risk for fungal use of non or incompletely sterilized equipment during invasive procedures. We conducted a literature review to help provide more accurate data on this unknown entity that are zygomycosis healthcare associated and whose weight in terms of public health is misjudged.
All cases of zygomycosis literature from January 1970 to December 2008 were considered, only those associated with a source of contamination identified or suspected in connection with a treatment procedure (medical devices, surgery, diagnostic or therapeutic procedures) ambulatory or hospital and that met zygomycosis definition of the classification of the EORTC / MSG (16) have been included.
A total of 169 cases of zygomycosis healthcare associated were selected, middle age 42 ± 16 years. Children under 15 accounted for 29% of the population. 61% were male. Medical and / or surgical treatment was performed in 78% of them. The overall mortality was 50%, 64% among newborns.
Comorbidities regrouped: transplanted solid organ (n = 40), cancers (n = 21), infants (n = 36), or immunosuppression related to treatment or to underlying diseases (n = 46) no identified risk factors (n = 26).Diabetes was described in 22% of patients. Most patients were hospitalized in surgery (41%) or intensive care unit (33%); 12% were receiving outpatient care.
All locations have been reported, with the majority of cutaneous lesions (57%), predominantly affecting neonates and patients who had surgery. Digestive locations (12%) were more represented in premature infants and immunocompromised patients not admitted to intensive care. Pulmonary disorders (6%) and rhinocérébrales (4%) were less frequent. Some locations were more anecdotal as endovascular infections, bone or eye.
The main pathogens involved were Rhizopus spp. (43%), Mucor spp. (9%) and Lichtheimia corymbifer(8%). The identification was not achieved in 28% of cases. Indeed, molecular biological tools were used in two publications.
Sporadic cases were incriminating described some care procedures such as catheters and drain (n = 29), use tape and bandages (n = 11), tooth extractions (n = 6), intravascular devices (n = 6), devices diabetic (insulin pumps, glucose monitoring device), peritoneal dialysis (n = 5), injections (vitamins, steroids), cutaneous hypersensitivity tests, nasal wicking lumbar biopsy. Organ transplants, mostly liver (17) and kidney (18) , could also be directly involved in the occurrence of zygomycosis. Several outbreaks involving elastic adhesive bandages (Elastoplast ® ), wooden tongue depressors of, and ostomy bags have been described (19) .
Each year some publications recount zygomycosis healthcare associated. In 2009-2010, 6 items incriminating care or medical device procedures such as intravenous catheters (20) , more cesareans (21) , a ligament reconstruction arthroscopically (22) , tooth extraction (23) , the installation of an oxygen sensor maintained with tape (24) and intake of allopurinol tablets and contaminated food preparations in hematology(25) . Also, healthcare associated zygomycosis have become a concern in highly immunocompromised patients in organ transplantation, hematology and neonatology. The cutaneous lesions are the most common.Immunocompetent patients are not spared when it comes to surgical procedures. The cases grouped zygomycosis occurring in a hospital should now be the subject of specific surveys looking for a source of contamination.
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- RICAI 30th (2010)