Re: Watch Out—Fungi a Danger to Cancer Patients (And others)

[Guest guest]

KC,

Good find! This is one of the first incidents - and it came from

nursing, not MDs! - recommending that cancer patients should

return to a " safe " home.

* Patients should avoid dusty areas and construction zones.

If they must pass through such an area, they should wear

an N95 respirator. They should keep at the home humidity

level at 40% to 50%. " Fungal spores are greater in the

natural environment than in the hospital, where we have

more control, " Ms McCollom said. " Controlling the relative

humidity will help. " (Comment: But many hospitals are lax,

especially during construction projects. Fungal infections

from that killed several in Tampa earlier).

* Patients should use air conditioners and dehumidifiers, but

not fans. The home should have adequate ventilation and

bathrooms and basements should be tiled or concrete, with

no carpeting. Patients should not vacuum, dust, or reuse

towels.

This is good general information. What is lacking is specifics on

how to evaluate if they have these conditions, and if not then how

to create them. The principles are " simple " but the successful

execution, as many of us here have learned the hard way, can be

difficult.

Carl Grimes

Healthy Habitats LLC

-----

Watch Out-Fungi a Danger to Cancer Patients

Debra Wood, RN

Oncology Nursing News - New York,n,USA

http://www.oncologynursingnews.com/Watch-OutFungi- a-Danger-to-

Cancer-Patients/article/150938/

LAKE BUENA VISTA, FLA-Fungus lives among us, typically causing

minimal trouble in healthy individuals. But for patients with

compromised immune systems, a fungal infection can often prove fatal.

" We're seeing a higher prevalence of fungal infections in our patient

population, " noted McCollom, RN, ND, CPON, a clinical manager

at Children's Medical Center Dallas. Dr McCollom spoke at the

Association of Pediatric Hematology/Oncology Nurses Annual

Conference.

Statistically, fungal sepsis has increased 207% in the last 20 years.

Fungal infections develop in 19% of people with acute lymphocytic

leukemia patients, 47% of those with acute myelogenous leukemia with

remission induction therapy, 5% of autograft transplant patients, and

18% to 45% of persons undergoing an unrelated allogeneic transplant.

According to Dr McCollom, 30% to 95% of these individuals will die.

Fungal spores float in the air. Once they land, they begin to grow in an

environment containing moisture, nutrients, and the right temperature.

Controlling moisture is the key to controlling fungal growth, advised Dr

McCollom.

People can inhale or ingest the spores. A healthy person's respiratory

tract cilia, normal flora, and immune system will prevent the fungus

from becoming harmful. But immunocompromised individuals often

cannot fight off fungal infections.

Many patients arrive for treatment colonized with fungi, and once their

immune system is suppressed by chemotherapy treatment, the fungi

flourish. Broadspectrum antibiotics, graft-versus-host disease,

intravenous catheters, and environmental contaminants also increase

the risk of fungal infections.

Three Main Types of Fungi

Dr McCollom described 3 fungus types- Fusarium, Candida, and

Aspergillus-that commonly cause infection in patients.

Fusarium is found on plants and in the soil. Hence, Ms McCollom's

hospital does not allow patients to have potted plants. " It's the most

emergent opportunistic infection in humans, " she reported.

Fusarium is often drug-resistant and can cause superficial and systemic

disease, with resultant thrombosis.

" Patients with a malignancy or stem-cell transplant often have a poor

outcome [with this fungal infection] because the immune system is so

suppressed, " Ms McCollom explained. " We use combination therapy, but

when [the disease is] invasive, it's typically fatal. "

Candida is the most common mycosis worldwide and the fourth most

common bloodborne infection. This fungus is found on human skin, in

the mucous membranes, and throughout the body, and grows rapidly.

Another common fungus, Aspergillus, is found in soil, building materials,

spices, and the hospital environment. Although most people breathe it in

daily and it is then dispatched by the immune system, Aspergillus can be

very invasive and start to take over in an immunocompromised patient.

Symptoms of fungal infection include wheezing, cough, fever, bloody

mucus, and hemorrhage. Infections are diagnosed by x-ray; by computed

tomography (CT) scan, which might show a halo shadow around the

fungal wall; by bronchial alveolar lavage; and by biopsy.

Treatment

Providers typically begin antifungal treatment on patients with

neutropenia who have had a fever for 5 or more days, when a blood

culture grows yeast, or when a CT scan indicates something suspicious.

" You want a drug that's fungistatic and fungicidal, " counseled Virginia

Koepsell, RN, MSN, MBA, CPON, a nursing educator at Children's

Medical Center Dallas. (Fungistatic drugs are used to stop fungi growth;

fungicides kill fungi.) " The optimal [drug] has wide-spectrum activity,

because you often don't know what [the infection] is in the beginning,

[and] is effective but has low toxicity and low cost. "

The 3 drug classes used to treat fungal infections are azoles, polyenes,

and echinocandins, also known as fungins. They are often given in

combination, with the different agents using different mechanisms of

action to combat the infection. " You can bring down the drug dose to get

less toxicity [with combinations], and it decreases the emergence of drug

resistance, " said Ms Koepsell.

Azoles inhibit fungal growth by preventing formation of ergosterol,

which is vital for cell membrane integrity. An older azole, fluconazole, is

fungistatic but will not kill fungi. It is often used to treat Candida

albicans.

Voriconazole is a newer drug that inhibits growth and kills the fungus.

It's commonly prescribed to treat Fusarium and Aspergillus infections.

Voriconazole is nephrotoxic when given intravenously. It is hepatotoxic

in the IV and oral formulations; therefore prescribers may need to

decrease the dose of cyclosporine or tacrolimus if those drugs are also

ordered. A high-fat meal will decrease absorption by 25%. About 30% of

patients report visual disturbances within 30 minutes of starting the

dose, but these resolve within another 30 minutes.

Polyenes or amphotericin derivatives interact with the cell membrane to

kill the fungus. Amphotericin B has been used for more than 50 years,

and although very little resistance has developed, the drug has many

toxicities. Nurses noticed that when it was given with lipids, patients

experienced fewer side effects, and now it is available in 3 lipid

formulations: Abelcet, Amphotec, and AmBisome. AmBisome can be

given in higher doses than amphotericin B, with fewer toxicities, but it is

more expensive. It causes potassium depletion and is not compatible

with normal saline. Because of sterility issues, nurses must administer

AmBisome within 6 hours of preparation. The patient should receive a

bolus of normal saline prior to starting the AmBisome intravenous

infusion to salt-load the kidneys and protect the renal tubules.

Echinocandins block synthesis of the fungal cell wall and are used in

treating Aspergillus and Candida. One such agent, caspofungin, is not

compatible with dextrose.

Providers also may add GM-CSF (granulocyte-macrophage colony-

stimulating factor) and interferon in an attempt to enhance the body's

immune response, especially when treating overwhelming fungal

infections.

" We want to reverse the immunosuppression, " clarified Ms Koepsell. " In

order for the patient to get over the infection, we have to boost the white-

cell count. "

Prevention

Hospitals have taken many measures to decrease the risk of fungal

infections, such as installing HEPA filters, controlling clutter, prohibiting

flowers and plants, and having nurses educate patients and their families

about methods of modifying the home environment.

Patients should avoid dusty areas and construction zones. If they must

pass through such an area, they should wear an N95 respirator. They

should keep at the home humidity level at 40% to 50%. " Fungal spores

are greater in the natural environment than in the hospital, where we

have more control, " Ms McCollom said. " Controlling the relative

humidity will help. "

Patients should use air conditioners and dehumidifiers, but not fans. The

home should have adequate ventilation and bathrooms and basements

should be tiled or concrete, with no carpeting. Patients should not

vacuum, dust, or reuse towels.

From the October 2009 Issue of ONN

----------

The following section of this message contains a file attachment

prepared for transmission using the Internet MIME message format.

If you are using Pegasus Mail, or any other MIME-compliant system,

you should be able to save it or view it from within your mailer.

If you cannot, please ask your system administrator for assistance.

---- File information -----------

File: DEFAULT.BMP

Date: 16 Jun 2009, 0:10

Size: 358 bytes.

Type: Unknown