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Outbreak of gastric mucormycosis associated with the use of wooden tongue depressors in critically ill patients

Abstract

Objective

To describe a nosocomial outbreak of gastric mucormycosis caused by Rhizopus microsporus var. rhizopodiformis in five adult patients admitted to an intensive care unit (ICU).

Design

Epidemiological surveillance study.

Setting

A 12-bed polyvalent ICU of an acute care teaching hospital in Pamplona, Spain.

Patients

Five patients admitted to the ICU requiring artificial ventilation, diagnosis on admission severe pneumonia in four patients and one polytrauma patient, within a 14-week period, were diagnosed with gastric mucormycosis based on microbiological and/or histopathological characteristics. Upper gastrointestinal bleeding was the presenting manifestation in 80% of patients.

Interventions

Filamentous fungi isolated at the microbiology laboratory of the hospital were examined at the national Mycology Reference Laboratory in Madrid.

Measurements and results

Rhizopus microsporus var. rhizopodiformis growth was detected in gastric aspiration samples, environmental samples, wooden tongue depressors used to prepare oral medications (and given to patients through a nasogastric catheter), and in some tongue depressors stored in unopened boxes unexposed to the ICU environment. All depressors were purchased from the same supplier. R. microsporus was not isolated from batches purchased at different times from the same supplier and from another supplier. The outbreak terminated when contaminated tongue depressors were withdrawn from use.

Conclusions

Wooden tongue depressors contaminated by R. microsporus var. rhizopodiformis used to prepare oral medications caused an outbreak of fungal gastritis with an attributable mortality of 40%. Wooden material should not be used in the hospital setting.

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References

  1. 1.

    Parfrey NA (1986) Improved diagnosis and prognosis of mucormycosis: a clinicopathologic study of 33 cases. Medicine (Baltimore) 65:113–123

    Google Scholar 

  2. 2.

    Khan LB (1963) Gastric mucormycosis: report of a case with a review of the literature. S Afr Med J 37:1265–1269

    PubMed  Google Scholar 

  3. 3.

    Corley DA, Lindeman N, Ostroff JW (1997) Survival with early diagnosis of invasive gastric mucormycosis in a heart transplant patient. Gastrointest Endosc 46:452–454

    CAS  PubMed  Google Scholar 

  4. 4.

    Thomson SR, Bade PG, Taams M, Chrystal V (1991) Gastrointestinal mucormycosis. Br J Surg 78:952–954

    CAS  PubMed  Google Scholar 

  5. 5.

    Lawson H, Schmaman A (1974) Gastric phycomycosis. Br J Surg 61:743–746

    CAS  PubMed  Google Scholar 

  6. 6.

    Ribes JA, Vanover-Sams CL, Baker DJ (2000) Zygomycetes in human disease. Clin Microbiol Rev 13:236–301

    CAS  Google Scholar 

  7. 7.

    García de Jalón J, Maraví-Poma E, Repáraz Abaitua F, Jiménez Urra I, Espatolero Esparza MJ, Gutiérrez Oliver A, Panizo Delgado A (1996) Incidencia de infecciones nosocomiales en una unidad de cuidados intensivos polivalente. Asociación a los factores de riesgo. Med Intensiva 20:6–14

    Google Scholar 

  8. 8.

    Baker RD (1957) Mucormycosis, a new disease? J Am Med Assoc 163:806–808

    Google Scholar 

  9. 9.

    Burchard KW (1992) Fungal Sepsis. Infect Dis Clin North Am 7:677–692

    Google Scholar 

  10. 10.

    Neame P, Rayner D (1960) Mucormycosis: a report on 22 cases. Arch Pathol 70:261–268

    PubMed  Google Scholar 

  11. 11.

    Verweij PE, Voss A, Donnelly JP, De Pauw B, Meis JFGM (1997) Wooden sticks as the source of a pseudoepidemic of infection with Rhizopus microsporus var. rhizopodiformis among immunocompromised patients. J Clin Microbiol 35:2422–2423

    PubMed  Google Scholar 

  12. 12.

    Leeming JG, Moss HA, Elliot TSJ (1996). Risk of tongue depressors to the immunocompromised. Lancet 348:889

    CAS  PubMed  Google Scholar 

  13. 13.

    Harper JJ, Coulter C, Lye GR, Nimmo GR (1996) Rhizopus and tongue depressors. Lancet 348:1250

    CAS  Google Scholar 

  14. 14.

    Holzel H, Macqeen S, MacDonald A, Alexander S, Campbell CK, Johnson EM, Warnock DW (1998) Rhizopus microsporus in wooden tongue depressors: a major threat or minor inconvenience? J Hosp Infection 38:113–118

    CAS  Google Scholar 

  15. 15.

    Mitchell SJ, Gray J, Morgan MEI, Hocking MD, Durbin GM (1996) Nosocomial infection with Rhizopus microsporus in preterm infants; association with wooden tongue depressors. Lancet 348:441–443

    Article  CAS  PubMed  Google Scholar 

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Acknowledgements

We thank Gilead Sciencies, S.L., for financial support in logistic aspects of the study, J. Mestre, B. Sesma, and J. Rello for critical review of the manuscript, R. Kimball for translation into English, and M. Pulido for editing the manuscript and for editorial assistance.

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Corresponding author

Correspondence to Enrique Maraví-Poma.

Additional information

This work was presented in part at the 11th Annual Congress of the European Society of Intensive Care Medicine (ESICM), Stockholm, Sweden, 1998.

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Maraví-Poma, E., Rodríguez-Tudela, J.L., de Jalón, J.G. et al. Outbreak of gastric mucormycosis associated with the use of wooden tongue depressors in critically ill patients. Intensive Care Med 30, 724–728 (2004). https://doi.org/10.1007/s00134-003-2132-1

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Keywords

  • Gastric mucormycosis
  • Wooden tongue depressors
  • Rhizopus microsporus var. rhizopodiformis
  • Gastrointestinal bleeding
  • Nasogastric catheter