Last data update: Jan 27, 2025. (Total: 48650 publications since 2009)
Records 1-30 (of 61 Records) |
Query Trace: Toda M[original query] |
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Epidemiology of coronavirus disease 2019-associated fungal infections in the intensive care unit: A single-center retrospective study
Little JS , McGwin G , Tushla L , Benedict K , Lyman MM , Toda M , Baddley JW , Pappas PG . Mycopathologia 2025 190 (1) 16 ![]() INTRODUCTION: Invasive fungal disease (IFD) is a morbid superinfection that can arise in critically ill patients with COVID-19 infection. Studies evaluating the full spectrum of COVID-19-associated fungal infections remain limited. METHODS: Single-center retrospective study assessing IFD in patients with COVID-19, hospitalized for ≥ 72 h in the intensive care unit (ICU) between 02/25/20 and 02/28/22 (n = 1410). IFD was assessed using consensus criteria (EORTC/MSGERC or ISHAM/ECMM criteria). T- and chi-square tests compared demographic/clinical characteristics between IFD and non-IFD patients. Cox proportional hazards regression estimated risk factors for in-hospital mortality. RESULTS: Of 1410 patients with severe COVID-19, 70 (5%) had a diagnosis of COVID-19-associated fungal infection with invasive candidiasis occurring in 3%, and invasive aspergillosis in 2%. Other fungal infections were rare. Patients with IFD had longer ICU stays (26 vs. 13 days; p < 0.001); increased rates of mechanical ventilation (99% vs. 70%; p < 0.001); and a higher risk of in-hospital death (69% vs. 36%; p < 0.001). On multivariable analysis, COVID-associated fungal infections were associated with an increased risk of in-hospital mortality. CONCLUSIONS: This real-world study of critically ill patients with COVID-19 demonstrated a low incidence of COVID-19-associated fungal infections with invasive candidiasis occurring most frequently. Fungal infections were associated with an increased risk of in-hospital mortality in this population. |
Prevalence and features of allergic bronchopulmonary aspergillosis, United States, 2016-2022
Benedict K , Gold JAW , Toda M , Hsu J . PLoS One 2025 20 (1) e0317054 The epidemiology of allergic bronchopulmonary aspergillosis (ABPA) in the United States is not well-described. To estimate national ABPA prevalence among patients with asthma or cystic fibrosis, characterize ABPA testing practices, and describe ABPA clinical features, treatment, and 6-month outcomes. We used the 2016-2022 Merative™ MarketScan® Commercial/Medicare and Multi-State Medicaid Databases to identify cohorts of patients with 1) asthma, 2) cystic fibrosis (CF), and 3) ABPA. We calculated ABPA prevalence per 10,000 patients with asthma or CF, assessed diagnostic testing for ABPA among patients with severe asthma, and described features of patients with ABPA using diagnosis and procedure codes. The overall ABPA prevalence among patients with asthma was 2.8/10,000 (Commercial/Medicare) and 1.0/10,000 (Medicaid). ABPA prevalence increased with asthma severity (Commercial/Medicare: mild 1.3, moderate 9.3, severe 70.6, Medicaid: mild 0.3, moderate 2.4, severe 32.4). Among patients with CF, ABPA prevalence was 183.7/10,000 (Commercial/Medicare) and 134.6/10,000 (Medicaid). Among patients with severe asthma, 10.3% (Commercial/Medicare) and 7.4% (Medicaid) received total immunoglobulin E testing, which is recommended for ABPA diagnosis. Among all patients with ABPA (Commercial/Medicare: n = 1,564, Medicaid: n = 410), ABPA treatments included inhaled corticosteroids (>70%), systemic corticosteroids (>62%), and antifungals (>18%). Patients with ABPA and Medicaid were more likely to experience hospitalization (45.1% vs. 22.5% of patients with Commercial/Medicare insurance) and respiratory failure (18.5% vs. 10.9%). This analysis provides initial estimates of national ABPA prevalence. Further studies could identify potential barriers to ABPA testing and investigate potential factors affecting payer-related differences in ABPA burden. |
Outbreak of blastomycosis among paper mill workers -- Michigan, November 2022-May 2023
Harvey RR , O'Connor AW , Stanton ML , Park JH , Shi D , Callaway PC , Liang X , LeBouf R , Bailey R , Fechter-Leggett E , Hennessee I , Toda M , Reik R , Stobierski MG , McFadden J , Palmer S , Millerick-May M , Yin R , Snyder M , Meece J , Olstadt J , Sterkel AK , Dargle S , Bree O , Weissman D , de Perio MA , Hines S , Cox-Ganser J . MMWR 2025 73 (5152) 1157-1162 Blastomycosis is a fungal disease caused by inhalation of Blastomyces spores from the environment that can result in severe pulmonary illness and high hospitalization rates. In early March 2023, Public Health Delta and Menominee Counties (Michigan) reported a cluster of blastomycosis cases among paper mill workers to the Michigan Department of Health and Human Services (MDHHS). MDHHS subsequently notified CDC. On March 17, paper mill management requested a health hazard evaluation (HHE) from CDC’s National Institute for Occupational Safety and Health (NIOSH) to investigate potential workplace exposures to Blastomyces and recommend prevention and control measures at the mill. The workplace epidemiologic investigation combined a NIOSH HHE medical survey consisting of a questionnaire on work and health with Blastomyces urine antigen testing of specimens obtained from workers to assist in case finding, with additional case information from MDHHS blastomycosis surveillance data. Assessment of 645 mill workers identified 162 cases of blastomycosis with illness onset during November 1, 2022-May 15, 2023, with the weekly case count peaking at 21 cases in early March 2023. HHE environmental sampling in and around the mill did not identify the source of workers' Blastomyces exposure in the mill. This outbreak was the largest documented blastomycosis outbreak in the United States, and the first associated with a paper mill or an industrial setting. A coordinated public health response facilitated swift prevention measures with recommendations focused on reducing workers' exposure to Blastomyces, including hazard communication, respiratory protection, mill cleaning, and ventilation system improvements. |
Coccidioidomycosis transmission through solid organ transplantation (2013-2022): A report of the Organ Procurement and Transplantation Network ad hoc Disease Transmission Advisory Committee
Lee DH , Abidi MZ , Fisher C , Hughart AL , Toda M , Williams S , Berry GJ , Graves R , Handarova D , Ho CS , Kittleson M , Levi ME , Livelli T , Marboe CC , Annamabhotla P , Miller RA , Sharma T , Sellers MT , Taimur S , Te HS , Trindade AJ , Wood RP , Zaffiri L , Pouch SM , Danziger-Isakov L . Transpl Infect Dis 2024 e14406 BACKGROUND: Coccidioidomycosis is a fungal infection that poses a serious risk when transmitted through organ transplantation. We analyzed cases reported to the Organ Procurement and Transplantation Network ad hoc Disease Transmission Advisory Committee from 2013 to 2022. METHODS: Donors and/or recipients who had positive Coccidioides immitis/posadasii serology, pathology, and/or culture were included in this study. Cases adjudicated as 'proven' or 'probable' were analyzed for donor infection risk factors, the timing of infection, transmission by organ type, clinical manifestations, and recipient outcomes. Patient and facility identifiers were removed prior to review. RESULTS: During this time period, 73 potential instances of Coccidioides donor disease transmission events were reported. Among them, infection was transmitted from seven deceased donors to eight recipients. All seven deceased donors had prior infection or exposure to regions where coccidioidomycosis is endemic. Of 20 individuals receiving organs from these donors, eight developed infection, resulting in a 40% transmission rate. The median time to diagnosis post-transplant was 39 days. Disseminated disease occurred in six recipients, five of whom died from the infection. Notably, none of the recipients who received prophylactic antifungal treatment died from the infection. CONCLUSION: Despite its rarity, donor-derived Coccidioides infection is a serious concern, particularly due to the high mortality rate in the early post-transplant period. To mitigate these risks, a thorough assessment of donor exposure history, coupled with donor serology and bronchoalveolar lavage cultures, can effectively guide post-transplant antifungal prophylaxis. Prompt reporting is crucial to prevent Coccidioides infections among other recipients. |
Human and canine blastomycosis cases associated with riverside neighborhood, Wisconsin, USA, December 2021-March 2022(1)
Segaloff HE , Wu K , Williams SL , Shaw S , Miko S , Parnell LA , Hanzlicek AS , Carlson KM , Lindsley M , Westergaard RP , Toda M , Gibbons-Burgener SN . Emerg Infect Dis 2024 30 (12) 2633-2638 We investigated a blastomycosis cluster among humans and canines in a neighborhood in Wisconsin, United States. We conducted interviews and collected serum specimens for Blastomyces antibody testing by enzyme immunoassay. Although no definitive exposure was identified, evidence supports potential exposures from the riverbank, riverside trails or yards, or construction dust. |
Epidemiological and clinical features of a large blastomycosis outbreak at a paper mill in Michigan
Hennessee I , Palmer S , Reik R , Miles-Jay A , Nawaz MY , Blankenship HM , Kramer R , Hughes A , Snyder M , Yin RL , Litvintseva AP , Parnell LA , Gade L , Chiller T , de Perio MA , Stobierski MG , McFadden J , Toda M . Clin Infect Dis 2024 ![]() ![]() BACKGROUND: Blastomycosis is an environmentally acquired fungal infection that can result in severe pulmonary illness and high hospitalization rates. In 2023, a blastomycosis outbreak was detected among workers at a paper mill in Delta County, Michigan. METHODS: We included patients with clinical and laboratory evidence of blastomycosis who had spent ≥40 hours in Delta County since September 1, 2022 and had illness onset December 1, 2022-July 1, 2023. We assessed epidemiological and clinical features of patients and evaluated factors associated with hospitalization. We performed whole-genome sequencing to characterize genetic relatedness of clinical isolates from eight patients. RESULTS: In total, 131 patients were identified; all had worked at or visited the mill. Sixteen patients (12%) were hospitalized; one died. Compared with non-hospitalized patients, more hospitalized patients had diabetes (p=0.03) and urine antigen titers above the lower limit of quantification (p<0.001). Hospitalized patients were also more likely to have had ≥1 healthcare visits before receiving a blastomycosis diagnostic test (p=0.02) and to have been treated with antibiotics prior to antifungal prescription (p=0.001). All sequenced isolates were identified as Blastomyces gilchristii and clustered into a distinct outbreak cluster. CONCLUSIONS: This was the largest documented blastomycosis outbreak in the United States. Epidemiologic evidence indicated exposures occurred at or near the mill, and genomic findings suggested a common exposure source. Patients with diabetes may have increased risk for hospitalization, and elevated urine antigen titers could indicate greater disease severity. Early suspicion of blastomycosis may prompt earlier diagnosis and treatment, potentially reducing unnecessary antibiotic prescriptions and improving patient outcomes. |
Investigation and successful control of a Candida auris outbreak at a tertiary health care facility in Kenya
Ombajo LA , Kanyua A , Ngugi R , Malcolm C , Berkow E , Gade L , Bancroft E , Osoro J , Njoroge R , Juma P , Ngirita M , Bore RC , Litvintseva A , Lyman M , Toda M . IJID Regions 2024 13 ![]() ![]() Objectives: This study aimed to conduct an epidemiological and genomic investigation of a hospital outbreak of Candida auris, and implement measures for its control. Methods: We collected demographic and clinical data from medical records of patients with C. auris from January 2017 to June 2019 after identifying increased cases in April 2019. Point-prevalence surveys for C. auris colonisation were conducted in the critical care units (CCU). Antifungal susceptibility testing and genomic sequencing of isolates were performed. A bundle of infection prevention and control measures was instituted. Results: Thirty-two patients with C. auris were identified. All patients had a history of CCU admission. A total of 283 screening swabs were obtained and 57 isolates of C. auris identified. Antifungal susceptibility testing was performed on 48 isolates. All but two isolates were resistant to fluconazole; one isolate was also resistant to amphotericin B. Forty-one of 46 isolate genomes were clonally related and formed a distinct genetic cluster in Clade III. C. auris colonisation reduced from 42% in June 2019 to 1% in August 2019, and no new hospital-acquired colonisation was identified in the subsequent 9 months. Conclusions: We identified a new genetic subcluster of Clade III C. auris. We also show that strict implementation of infection prevention measures can lead to substantial reductions in C. auris transmission. © 2024 The Authors |
Associations between Minority Health Social Vulnerability Index scores, rurality, and histoplasmosis incidence, 8 US States
Smith DJ , Rajeev M , Boyd K , Benedict K , Hennessee I , Rothfeldt L , Austin C , Steppig ME , Patel D , Reik R , Ireland M , Sedivy J , Gibbons-Burgener S , Calanan RM , Williams SL , Rockhill S , Toda M . Emerg Infect Dis 2024 30 (10) 2016-2024 To explore associations between histoplasmosis and race and ethnicity, socioeconomic status, and rurality, we conducted an in-depth analysis of social determinants of health and histoplasmosis in 8 US states. Using the Minority Health Social Vulnerability Index (MH SVI), we analyzed county-level histoplasmosis incidence (cases/100,000 population) from the 8 states by applying generalized linear mixed hurdle models. We found that histoplasmosis incidence was higher in counties with limited healthcare infrastructure and access as measured by the MH SVI and in more rural counties. Other social determinants of health measured by the MH SVI tool either were not significantly or were inconsistently associated with histoplasmosis incidence. Increased awareness of histoplasmosis, more accessible diagnostic tests, and investment in rural health services could address histoplasmosis-related health disparities. |
Geographical distribution of the Cryptococcus gattii species complex: a systematic review
Poplin V , Smith C , Caceres DH , Herkert PF , Jegede O , Thompson GR 3rd , Baddley JW , Schwartz IS , Kubat R , Deka MA , Toda M , Lockhart SR , Chiller T , Hagen F , Bahr NC . Lancet Microbe 2024 100921 ![]() The taxonomy of the Cryptococcus gattii species complex continues to evolve, and has been divided into five pathogenic species. The objective of this systematic review was to summarise the geographical distribution of the C gattii species complex and the species within the C gattii species complex. We searched PubMed for articles related to human, animal, ecological, or laboratory-based studies of C gattii species complex isolates with traceable geographical origin published from January, 1970, until September, 2021. Having extracted their geographical origin, we used ArcMap to construct maps according to the highest degree of resolution allowed by their reported taxonomy, to reflect the most likely area of transmission on the basis of published reports of human isolates. 604 such articles were included in the study. This review indicated that although C gattii species complex isolates have been reported globally, understanding their heterogeneous geographical distribution by species can have implications for researchers and clinicians in formulating research questions and considering diagnostic quandaries. |
Testing for blastomycosis, coccidioidomycosis, and histoplasmosis at a major commercial laboratory, United States, 2019-2024
Benedict K , Williams SL , Smith DJ , Lindsley MD , Lockhart SR , Toda M . Open Forum Infect Dis 2024 11 (8) ofae448 BACKGROUND: Blastomycosis, coccidioidomycosis, and histoplasmosis are environmentally acquired fungal diseases that clinically resemble bacterial and viral community-acquired pneumonia and require laboratory testing for diagnosis. Patients frequently present to primary care and experience diagnostic delays when a fungal etiology is not initially suspected. Current national-level public health surveillance for these diseases is limited and does not include laboratory data, so nationwide testing practices are unknown. METHODS: We identified laboratory tests for blastomycosis, coccidioidomycosis, and histoplasmosis ordered during 1 March 2019-29 February 2024 and performed within a major national commercial laboratory system. We analyzed test results, patient and healthcare provider features, reasons for testing, and temporal trends. RESULTS: Results included 5693 Blastomyces complement fixation tests (of those, 12% were positive), 71 858 immunodiffusion tests (0.1% positive), and 1186 serum enzyme immunoassay (EIA) tests (11% positive); 154 989 Coccidioides EIA immunoglobulin M results (5% positive) and 154 968 immunoglobulin G results (8% positive); and 46 346 Histoplasma complement fixation tests (30% positive), 49 062 immunodiffusion tests (1% positive), 35 506 serum EIA tests (4% positive), and 82 489 urine EIA tests (2% positive). Most histoplasmosis (58%-74%) and blastomycosis (42%-68%) tests were ordered from hospitals, whereas coccidioidomycosis tests were most frequently ordered by primary care providers (40%). A yearly average of 2727 positive tests were ordered by healthcare providers in states without public health surveillance for these diseases. CONCLUSIONS: Blastomycosis, coccidioidomycosis, and histoplasmosis are likely underdetected in primary care settings or by public health surveillance. Increased testing by primary care providers and expanded surveillance are needed to reduce disease burden. |
Fungal infections and social determinants of health: Using data to identify disparities
Williams SL , Benedict K , Toda M . Curr Fungal Infect Rep 2024 18(2) 88-94 Purpose of Review: Fungal diseases disproportionately affect certain demographic populations, but few studies have thoroughly investigated the drivers of those disparities. We summarize data sources that can be considered to explore potential associations between fungal diseases and social determinants of health in the United States. Recent Findings: Sociodemographic disparities are apparent in fungal diseases, and social determinants of health (e.g., income, living conditions, and healthcare access) may be associated with increased risk of infection, severe disease, and poor health outcomes. Summary: Numerous data sources are available in the United States to analyze the potential association between fungal diseases and underlying social determinants of health. Each source has benefits and limitations that should be considered in the development of analysis plans. Inherent challenges to all fungal disease data (e.g., underdiagnosis, underreporting, and inability to detect people who do not seek medical care) should be noted and accounted for in interpretation of results. Copyright © This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply 2024. |
Effects of climate change on fungal infections
Williams SL , Toda M , Chiller T , Brunkard JM , Litvintseva AP . PLoS Pathog 2024 20 (5) e1012219 ![]() ![]() |
Sporotrichosis cluster in domestic cats and veterinary technician, Kansas, USA, 2022
Hennessee I , Barber E , Petro E , Lindemann S , Buss B , Santos A , Gade L , Lockhart SR , Sexton DJ , Chiller T , Toda M . Emerg Infect Dis 2024 30 (5) 1053-1055 ![]() ![]() We describe a feline sporotrichosis cluster and zoonotic transmission between one of the affected cats and a technician at a veterinary clinic in Kansas, USA. Increased awareness of sporotrichosis and the potential for zoonotic transmission could help veterinary professionals manage feline cases and take precautions to prevent human acquisition. |
Surveillance for Coccidioidomycosis, Histoplasmosis, and Blastomycosis During the COVID-19 Pandemic - United States, 2019-2021
Williams SL , Smith DJ , Benedict K , Ahlers JR , Austin C , Birn R , Carter AM , Christophe NN , Cibulskas K , Cieslak PR , Gibbons-Burgener SN , Gosciminski M , Ireland MJ , Lazenby KV , Loftus T , Lunquest K , Mathewson AA , Nguyen AD , Oltean HN , Osborn B , Petro EM , Power DJ , Reik RR , Schlosser L , Sedivy J , Smelser CB , Chiller T , Toda M . MMWR Morb Mortal Wkly Rep 2024 73 (11) 239-244 Coccidioidomycosis, histoplasmosis, and blastomycosis are lower respiratory tract fungal infections whose signs and symptoms can resemble those of other respiratory illnesses, including pneumonia caused by bacterial or viral etiologies; this overlap in clinical presentation might lead to missed or delayed diagnoses. The causative fungi live in the environment, often in soil or plant matter. To describe the epidemiologic characteristics of cases of coccidioidomycosis, histoplasmosis, and blastomycosis during the COVID-19 pandemic, CDC analyzed case surveillance data for 2019-2021. During this period, a total of 59,655 coccidioidomycosis cases, 3,595 histoplasmosis cases, and 719 blastomycosis cases were reported to CDC. In 2020, fewer cases of each disease occurred in spring compared with other seasons, and most cases occurred in fall; national seasonality is not typically observed, and cases were seasonally distributed more evenly in 2019 and 2021. Fewer cases coinciding with the start of the COVID-19 pandemic, along with an unusually high blastomycosis case fatality rate in 2021 (17% compared with more typical rates of 8%-10%), suggest that the pandemic might have affected patients' health care-seeking behavior, public health reporting practices, or clinical management of these diseases. Increased awareness and education are needed to encourage health care providers to consider fungal diseases and to identify pneumonia of fungal etiology. Standardized diagnostic guidance and informational resources for fungal testing could be incorporated into broader respiratory disease awareness and preparedness efforts to improve early diagnosis of coccidioidomycosis, histoplasmosis, and blastomycosis. |
Low incidence of invasive fungal infections in a large observational cohort of patients initiating IL-17 or IL-23 inhibitor therapy, United States, 2016-2022
Bahr NC , Benedict K , Toda M , Gold JAW , Lipner SR . J Am Acad Dermatol 2024 |
Healthcare use and health disparities associated with mold exposure diagnosis codes
Benedict K , Chew GL , Hsu J , Toda M , Gold JAW . J Allergy Clin Immunol Pract 2024 Medicaid and commercial health insurance claims databases revealed disparities in patients assigned the ICD-10 code "Contact with and (suspected) exposure to mold (toxic)" by insurance type, age, and sex. Allergic rhinitis was the most common concomitant diagnosis. |
Understanding the exposure risk of aerosolized Coccidioides in a Valley fever endemic metropolis
Porter WT , Gade L , Montfort P , Mihaljevic JR , Bowers JR , Willman A , Klimowski BA , LaFleur BJ , Sunenshine RH , Collins J , Adame G , Brady S , Komatsu KK , Williams S , Toda M , Chiller T , Litvintseva AP , Engelthaler DM . Sci Rep 2024 14 (1) 1311 Coccidioides is the fungal causative agent of Valley fever, a primarily pulmonary disease caused by inhalation of fungal arthroconidia, or spores. Although Coccidioides has been an established pathogen for 120 years and is responsible for hundreds of thousands of infections per year, little is known about when and where infectious Coccidioides arthroconidia are present within the ambient air in endemic regions. Long-term air sampling programs provide a means to investigate these characteristics across space and time. Here we present data from > 18 months of collections from 11 air sampling sites across the Phoenix, Arizona, metropolitan area. Overall, prevalence was highly variable across space and time with no obvious spatial or temporal correlations. Several high prevalence periods were identified at select sites, with no obvious spatial or temporal associations. Comparing these data with weather and environmental factor data, wind gusts and temperature were positively associated with Coccidioides detection, while soil moisture was negatively associated with Coccidioides detection. These results provide critical insights into the frequency and distribution of airborne arthroconidia and the associated risk of inhalation and potential disease that is present across space and time in a highly endemic locale. |
Clinical testing guidance for coccidioidomycosis, histoplasmosis, and blastomycosis in patients with community-acquired pneumonia for primary and urgent care providers
Smith DJ , Free RJ , Thompson Iii GR , Baddley JW , Pappas PG , Benedict K , Gold JAW , Tushla LA , Chiller T , Jackson BR , Toda M . Clin Infect Dis 2023 Coccidioidomycosis, histoplasmosis, and blastomycosis are underrecognized and frequently misdiagnosed fungal infections that can clinically resemble bacterial and viral community-acquired pneumonia (CAP). This guidance is intended to help clinicians in outpatient settings test for these fungal diseases in patients with CAP to reduce misdiagnoses, unnecessary antibacterial use, and poor outcomes. |
Antifungal therapeutic drug monitoring practices: Results of an Emerging Infections Network Survey
Benedict K , Gold JAW , Beekmann SE , Polgreen PM , Toda M , Smith DJ . Open Forum Infect Dis 2023 10 (9) ofad468 In a survey of 523 infectious disease specialists, a moderate to high percentage reported using any antifungal therapeutic drug monitoring (TDM) during itraconazole (72%), posaconazole (72%), and voriconazole (90%) treatment, and a low to moderate percentage reported using any antifungal TDM during prophylaxis (32%, 55%, and 65%, respectively). Long turnaround times for send-out TDM testing and logistical difficulties were frequent barriers. |
Blastomycosis-associated hospitalizations, United States, 2010-2020
Benedict K , Hennessee I , Gold JAW , Smith DJ , Williams S , Toda M . J Fungi (Basel) 2023 9 (9) BACKGROUND: Blastomycosis is an environmentally acquired fungal disease that can cause severe illness, with approximately 65% of reported cases requiring hospitalization. Recent trends in blastomycosis-associated hospitalizations in the United States have not been described. METHODS: We analyzed hospital discharge data from the Healthcare Cost and Utilization Project (HCUP) National (Nationwide) Inpatient Sample. We calculated hospitalization rates per 100,000 population using U.S. census data and examined factors associated with in-hospital mortality. RESULTS: An estimated 11,776 blastomycosis-associated hospitalizations occurred during 2010-2020 (average yearly rate 0.3 per 100,000 persons), with no apparent temporal trend. Rates were consistently highest among persons ≥65 years old and males. In-hospital death occurred in 7.9% and approximately doubled from 3.9% in 2010 to 8.5% in 2020. Older age, chronic obstructive pulmonary disease, and malignancy were associated with mortality. CONCLUSIONS: Blastomycosis-associated hospitalizations can result in poor outcomes, underscoring the continued need for attention to early detection and treatment of blastomycosis and monitoring of disease trends. |
Public health research priorities for fungal diseases: A multidisciplinary approach to save lives
Smith DJ , Gold JAW , Benedict K , Wu K , Lyman M , Jordan A , Medina N , Lockhart SR , Sexton DJ , Chow NA , Jackson BR , Litvintseva AP , Toda M , Chiller T . J Fungi (Basel) 2023 9 (8) Fungal infections can cause severe disease and death and impose a substantial economic burden on healthcare systems. Public health research requires a multidisciplinary approach and is essential to help save lives and prevent disability from fungal diseases. In this manuscript, we outline the main public health research priorities for fungal diseases, including the measurement of the fungal disease burden and distribution and the need for improved diagnostics, therapeutics, and vaccines. Characterizing the public health, economic, health system, and individual burden caused by fungal diseases can provide critical insights to promote better prevention and treatment. The development and validation of fungal diagnostic tests that are rapid, accurate, and cost-effective can improve testing practices. Understanding best practices for antifungal prophylaxis can optimize prevention in at-risk populations, while research on antifungal resistance can improve patient outcomes. Investment in vaccines may eliminate certain fungal diseases or lower incidence and mortality. Public health research priorities and approaches may vary by fungal pathogen. |
Fatal invasive mold infections after transplantation of organs recovered from drowned donors, United States, 2011-2021
Wu K , Annambhotla P , Free RJ , Ritter JM , Leitgeb B , Jackson BR , Toda M , Basavaraju SV , Gold JAW . Emerg Infect Dis 2023 29 (7) 1455-1458 Drowned organ donors can be exposed to environmental molds through the aspiration of water; transplantation of exposed organs can cause invasive mold infections in recipients. We describe 4 rapidly fatal cases of potentially donor-derived invasive mold infections in the United States, highlighting the importance of maintaining clinical suspicion for these infections in transplant recipients. |
Low rates of antifungal therapeutic drug monitoring among inpatients who received itraconazole, posaconazole, or voriconazole, United States, 2019-2021
Benedict K , Gold JAW , Toda M , Thompson GR 3rd , Wiederhold NP , Smith DJ . Open Forum Infect Dis 2023 10 (8) ofad389 Antifungal therapeutic drug monitoring (TDM) is recommended for hospitalized patients receiving itraconazole, posaconazole, or voriconazole for treatment or prophylaxis. In this analysis of hospital-based data, TDM was uncommonly performed (15.8%) in a large cohort of eligible patients, suggesting missed opportunities to avoid subtherapeutic drug levels and minimize toxicity. |
Increased hospitalizations involving fungal infections during COVID-19 pandemic, United States, January 2020-December 2021
Gold JAW , Adjei S , Gundlapalli AV , Huang YA , Chiller T , Benedict K , Toda M . Emerg Infect Dis 2023 29 (7) 1433-1437 Hospitalizations involving fungal infections increased 8.5% each year in the United States during 2019-2021. During 2020-2021, patients hospitalized with COVID-19-associated fungal infections had higher (48.5%) in-hospital mortality rates than those with non-COVID-19-associated fungal infections (12.3%). Improved fungal disease surveillance is needed, particularly during respiratory virus pandemics. |
Fungal pathogens as causes of acute respiratory illness in hospitalized veterans: Frequency of fungal positive test results using rapid immunodiagnostic assays
Caceres DH , Rodriguez-Barradas MC , Whitaker M , Jackson BR , Kim L , Surie D , Cikesh B , Lindsley MD , McCotter OZ , Berkow EL , Toda M . J Fungi (Basel) 2023 9 (4) Fungal respiratory illnesses caused by endemic mycoses can be nonspecific and are often mistaken for viral or bacterial infections. We performed fungal testing on serum specimens from patients hospitalized with acute respiratory illness (ARI) to assess the possible role of endemic fungi as etiologic agents. Patients hospitalized with ARI at a Veterans Affairs hospital in Houston, Texas, during November 2016-August 2017 were enrolled. Epidemiologic and clinical data, nasopharyngeal and oropharyngeal samples for viral testing (PCR), and serum specimens were collected at admission. We retrospectively tested remnant sera from a subset of patients with negative initial viral testing using immunoassays for the detection of Coccidioides and Histoplasma antibodies (Ab) and Cryptococcus, Aspergillus, and Histoplasma antigens (Ag). Of 224 patient serum specimens tested, 49 (22%) had positive results for fungal pathogens, including 30 (13%) by Coccidioides immunodiagnostic assays, 19 (8%) by Histoplasma immunodiagnostic assays, 2 (1%) by Aspergillus Ag, and none by Cryptococcus Ag testing. A high proportion of veterans hospitalized with ARI had positive serological results for fungal pathogens, primarily endemic mycoses, which cause fungal pneumonia. The high proportion of Coccidioides positivity is unexpected as this fungus is not thought to be common in southeastern Texas or metropolitan Houston, though is known to be endemic in southwestern Texas. Although serological testing suffers from low specificity, these results suggest that these fungi may be more common causes of ARI in southeast Texas than commonly appreciated and more increased clinical evaluation may be warranted. |
Notes from the field: Cluster of blastomycosis among neighborhood residents - St. Croix County, Wisconsin, 2022
Segaloff HE , Wu K , Shaw S , Klasen EM , Peterson L , Lindberg S , Williams SL , Wiese A , Bellay YM , Smith M , Engen K , Toda M , Gibbons-Burgener S . MMWR Morb Mortal Wkly Rep 2023 72 (13) 348-349 Blastomycosis, caused by the fungus Blastomyces, is a rare but potentially serious infection in humans and animals. Blastomyces is endemic in Wisconsin, which reports the highest incidence of Blastomyces infection in the country, with an estimated annual statewide incidence of 2.1 cases per 100,000 residents. Some high-incidence counties report 20–40 cases per 100,000 population (1,2). Blastomyces is also found in other midwestern, south-central, and southeastern states, and lives in moist, organic soils and decaying wood and leaves. Infections typically occur when Blastomyces spores are inhaled. Blastomyces infections do not spread between humans and animals through the air. Blastomycosis usually begins with mild respiratory symptoms, which often self-resolve, but can progress to a severe, and occasionally fatal, disease without antifungal treatment. In February 2022, a veterinarian in St. Croix County, Wisconsin, alerted the Wisconsin Department of Agriculture, Trade and Consumer Protection (DATCP) and the Wisconsin Department of Health Services (DHS) of four dogs with diagnoses of blastomycosis, all living within a 1-mile area. Review of surveillance data identified two human cases reported in the same area within 3 weeks of the canine cases. With 1–5 human cases reported annually, St. Croix County is not considered an area with hyperendemic transmission. |
Diagnosis codes for mold infections and mold exposure before and after Hurricane Harvey among a commercially insured population-Houston, Texas, 2016-2018
Benedict K , Jackson BR , Toda M . Disaster Med Public Health Prep 2023 17 1-10 OBJECTIVE: Indoor mold after flooding poses health risks including rare but serious invasive mold infections. The purpose of this study was to evaluate use of International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis codes for mold infection and mold exposure in Houston, Texas during the year before and the year after Hurricane Harvey. METHODS: This study used data from MarketScan, a large health insurance claims database. RESULTS: The incidence of invasive mold infections remained unchanged in the year after Hurricane Harvey; however, the incidence of diagnosis codes for mold exposure nearly doubled compared with the year before the hurricane (6.3 vs. 11.0 per 100,000 enrollees, rate ratio: 1.7, 95% confidence interval 1.0-3.1). CONCLUSIONS: Diagnosis codes alone may not be sufficiently sensitive to detect changes in invasive mold infection rates within this population and timeframe, demonstrating the need for more comprehensive studies. |
Invasive mold infections following Hurricane Harvey-Houston, Texas
Toda M , Williams S , Jackson BR , Wurster S , Serpa JA , Nigo M , Grimes CZ , Atmar RL , Chiller TM , Ostrosky-Zeichner L , Kontoyiannis DP . Open Forum Infect Dis 2023 10 (3) ofad093 BACKGROUND: Characterizing invasive mold infection (IMI) epidemiology in the context of large flooding events is important for public health planning and clinical decision making. METHODS: We assessed IMI incidence (per 10 000 healthcare encounters) 1 year before and after Hurricane Harvey at 4 hospitals in Houston, Texas. Potential IMI cases were assigned as proven or probable cases using established definitions, and surveillance cases using a novel definition. We used rate ratios to describe IMI incidence and multivariable logistic regression to examine patient characteristics associated with IMI case status. RESULTS: IMI incidence was significantly higher posthurricane (3.69 cases) than prehurricane (2.50 cases) (rate ratio, 1.48 [95% confidence interval, 1.10-2.00]), largely driven by surveillance IMI cases. Aspergillus was the most common species cultured (33.5% prehurricane and 39.9% posthurricane). About one-quarter (25.8%) of IMI patients lacked classical IMI risk factors such as hematologic malignancy and transplantations. Overall, 45.1% of IMI patients received intensive care, and in-hospital all-cause mortality was 24.2%. CONCLUSIONS: IMI incidence likely increased following Hurricane Harvey and outcomes for IMI patients were severe. Patient and clinician education on IMI prevention and identification is warranted, particularly as the frequency of extreme weather events increases due to climate change. |
Investigation of a prolonged and large outbreak of healthcare-associated mucormycosis cases in an acute care hospital-Arkansas, June 2019-May 2021
Jordan A , James AE , Gold JAW , Wu K , Glowicz J , Wolfe F , Vyas K , Litvintseva A , Gade L , Liverett H , Alverson M , Burgess M , Wilson A , Li R , Benowitz I , Gulley T , Patil N , Chakravorty R , Chu W , Kothari A , Jackson BR , Garner K , Toda M . Open Forum Infect Dis 2022 9 (10) ofac510 BACKGROUND: Outbreaks of healthcare-associated mucormycosis (HCM), a life-threatening fungal infection, have been attributed to multiple sources, including contaminated healthcare linens. In 2020, staff at Hospital A in Arkansas alerted public health officials of a potential HCM outbreak. METHODS: We collected data on patients at Hospital A who had invasive mucormycosis during January 2017-June 2021 and calculated annual incidence of HCM (defined as mucormycosis diagnosed within ≥7 days after hospital admission). We performed targeted environmental assessments, including linen sampling at the hospital, to identify potential sources of infection. RESULTS: During the outbreak period (June 2019-June 2021), 16 patients had HCM; clinical features were similar between HCM patients and non-HCM patients. Hospital-wide HCM incidence (per 100 000 patient-days) increased from 0 in 2018 to 3 in 2019 and 6 in 2020. For the 16 HCM patients, the most common underlying medical conditions were hematologic malignancy (56%) and recent traumatic injury (38%); 38% of HCM patients died in-hospital. Healthcare-associated mucormycosis cases were not epidemiologically linked by common procedures, products, units, or rooms. At Hospital A and its contracted offsite laundry provider, suboptimal handling of laundered linens and inadequate environmental controls to prevent mucormycete contamination were observed. We detected Rhizopus on 9 (9%) of 98 linens sampled at the hospital, including on linens that had just arrived from the laundry facility. CONCLUSIONS: We describe the largest, single-center, HCM outbreak reported to date. Our findings underscore the importance of hospital-based monitoring for HCM and increased attention to the safe handling of laundered linens. |
Surveillance for coccidioidomycosis, histoplasmosis, and blastomycosis - United States, 2019
Smith Dallas J , Williams Samantha L , Benedict Kaitlin M , Jackson Brendan R , Toda Mitsuru . MMWR Surveill Summ 2022 71 (7) 1-14 Problem/Condition: Coccidioidomycosis, histoplasmosis, and blastomycosis are underdiagnosed fungal diseases that often mimic bacterial or viral pneumonia and can cause disseminated disease and death. These diseases are caused by inhalation of fungal spores that have distinct geographic niches in the environment (e.g., soil or dust), and distribution is highly susceptible to climate changes such as expanding arid regions for coccidioidomycosis, the northward expansion of histoplasmosis, and areas like New York reporting cases of blastomycosis previously thought to be nonendemic. The national incidence of coccidioidomycosis, histoplasmosis, and blastomycosis is poorly characterized. Reporting Period: 2019. Description of System: The National Notifiable Diseases Surveillance System (NNDSS) tracks cases of coccidioidomycosis, a nationally notifiable condition reported to CDC by 26 states and the District of Columbia. Neither histoplasmosis nor blastomycosis is a nationally notifiable condition; however, histoplasmosis is voluntarily reported in 13 states and blastomycosis in five states. Health departments classify cases based on the definitions established by the Council of State and Territorial Epidemiologists. Results: In 2019, a total of 20,061 confirmed coccidioidomycosis, 1,124 confirmed and probable histoplasmosis, and 240 confirmed and probable blastomycosis cases were reported to CDC. Arizona and California reported 97% of coccidioidomycosis cases, and Minnesota and Wisconsin reported 75% of blastomycosis cases. Illinois reported the greatest percentage (26%) of histoplasmosis cases. All three diseases were more common among males, and the proportion for blastomycosis (70%) was substantially higher than for histoplasmosis (56%) or coccidioidomycosis (52%). Coccidioidomycosis incidence was approximately four times higher for non-Hispanic American Indian or Alaska Native (AI/AN) persons (17.3 per 100,000 population) and almost three times higher for Hispanic or Latino persons (11.2) compared with non-Hispanic White (White) persons (4.1). Histoplasmosis incidence was similar across racial and ethnic categories (range: 0.9-1.3). Blastomycosis incidence was approximately six times as high among AI/AN persons (4.5) and approximately twice as high among non-Hispanic Asian and Native Hawaiian or other Pacific Islander persons (1.6) compared with White persons (0.7). More than one half of histoplasmosis (54%) and blastomycosis (65%) patients were hospitalized, and 5% of histoplasmosis and 9% of blastomycosis patients died. States in which coccidioidomycosis is not known to be endemic had more cases in spring (March, April, and May) than during other seasons, whereas the number of cases peaked slightly in autumn (September, October, and November) for histoplasmosis and in winter (December, January, and February) for blastomycosis. Interpretation: Coccidioidomycosis, histoplasmosis, and blastomycosis are diseases occurring in geographical niches within the United States. These diseases cause substantial illness, with approximately 20,000 coccidioidomycosis cases reported in 2019. Although substantially fewer histoplasmosis and blastomycosis cases were reported, surveillance was much more limited and underdiagnosis was likely, as evidenced by high hospitalization and death rates. This suggests that persons with milder symptoms might not seek medical evaluation and the symptoms self-resolve or the illnesses are misdiagnosed as other, more common respiratory diseases. Public Health Action: Improved surveillance is necessary to better characterize coccidioidomycosis severity and to improve detection of histoplasmosis and blastomycosis. These findings might guide improvements in testing practices that enable timely diagnosis and treatment of fungal diseases. Clinicians and health care professionals should consider coccidioidomycosis, histoplasmosis, and blastomycosis in patients with community-acquired pneumonia or other acute infections of the lower respiratory tract who live in or have traveled to areas where the causative ungi are known to be present in the environment. Culturally appropriate tailored educational messages might help improve diagnosis and treatment. Public health response to these three diseases is hindered because information gathered from states' routine surveillance does not include data on populations at risk and sources of exposure. Broader surveillance that includes expansion to other states and more detail about potential exposures and relevant host factors can describe epidemiologic trends, populations at risk, and disease prevention strategies. |
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