Presentation is loading. Please wait.

Presentation is loading. Please wait.

Impact of air decontamination by use of Plasmers on the occurrence of invasive aspergillosis in patients at risk in hematological ward Aho Glélé LS**,

Similar presentations


Presentation on theme: "Impact of air decontamination by use of Plasmers on the occurrence of invasive aspergillosis in patients at risk in hematological ward Aho Glélé LS**,"— Presentation transcript:

1 Impact of air decontamination by use of Plasmers on the occurrence of invasive aspergillosis in patients at risk in hematological ward Aho Glélé LS**, Lafon I*, Ferrant M *, Barry M *, Astruc K**, Bonnin A***, Caillot D* Hematology; ** Epidemiology and Hospital hygiene; *** Mycology Dijon (France) Denver, June 2008

2 Context

3 Aspergillosis Aspergillus spp. and other moulds –=> Life-threatening opportunistic infections In immunocompromised patients Indoor contamination and construction work –=> Liberate fungal spores Major source of nosocomial aspergillosis

4 Aspergillosis In immunocompromised patients –Respiratory tract colonization by Aspergillus is associated with increased risk of invasive aspergillosis (IA) »Wald A et al.. J Infect Dis 1997;175: »Perfect JR et al. Clin Infect Dis 2001;33:

5 Aspergillosis Incidence rates of IA –Range from 4-26% in allogenic bone marrow transplant patients –5-25% in acute leukemia patients IA associated mortality rates –Range from 74-92% »Denning DW.Clin Infect Dis 1998;26: »Singh N et al. Clin Microbiol Rev 2005;18:44-69 »Latge´ JP. Clin Microbiol Rev 1999;12:

6 Previous study : Indoor fungal contamination surveillance program Implemented one year before building work – To establish baseline levels of contamination Prospective examination of air and surface fungal contamination –Following use, or not, of plasmer units –Adult and paediatric haematology units

7 plasmer treated rooms –Significant reductions in overall fungal contamination For air and surface samples –In both clinical units For A. fumigatus in the air plasmer units may provide an efficient method for reducing indoor fungal contamination in hospitals »Sixt et al. J hosp Infect 2006; 65(2): Previous study : Indoor fungal contamination surveillance program

8 Objectives

9 To assess the impact of air decontamination by use of Plasmers on the occurrence of invasive aspergillosis In patients at risk –In hematological ward i.e follows next study –Clinical outcome instead of environnemental microbiologic outcome

10 Setting

11 Setting : Dijon hospital Tertiary care institution –Northeast France Hospital involved in a renovation program –Construction of two buildings adjacent to clinical units receiving patients at high risk of fungal infection –Hematology unit –Infectious Diseases unit

12 Flow Nurses Room 10(4) Room 1 Nurses Hematology ward University Hospital Dijon « Protected » Sector Plasmair® 1 by room Since 07/20/2004 Conventional Sector Room 10(4) Room 1 Room 2 Room 1

13 Participants

14 Inclusion –Acute Myeloid leukemia (AML) –Acute Lymphoid leukemia (ALL) –See flow chart Non inclusion –Burkitt n=3

15 From 01/01/2000 to /12/31/2007 Proven IPA n = 17 (27%) Probable IPA n = 41 (65%) Possible IPA n = 5 (8%) 63 IPA (occurred in the department of hematology) MSG & IFIG/EORTC criteria 798 episodes of aplasia at very high risk of aspergillosis 435 patients with AML or ALL

16 Intervention and methods

17 Intervention : plasmer Mobile air-decontamination unit : Not based on filtration Destruction of airborne organisms through a three-step process –Exposure to high electric fields Deform and alter membrane or cell-wall –Subsequent bombardment with positive and negative ions Destroy internal structures –Electrostatic nano-filtration

18 Intervention: plasmer Electricity supply Three modes of activity –Correspond to increasing air-exchange capacity and increasing noise Cost –One unit : about Euros Maintenance needed –As for all kind of devices…

19 Intervention: others devices Standard Room Filtration and positive air-pressure –Laminar Flow –Class 10 4 »Federal Standard 209D

20 Methods Diagnostic –MSG & IFIG/EORTC criteria »Ascioglu et al. Clin Infect Dis. 2002: 7-14 Statistical analysis –Univariate analysis Before and after plasmers comparisons Classical tests, as appropriate –Fischer exact test, chi2 test –Kruskall Wallis, T-test

21 Methods: multivariate analysis Variable to explain –Occurrence of IPA (probability of) Explanatory variables –Age (A) –Sex (S) –Type of leukemia (L; AML or ALL) –De novo patient (DN; Yes or No) –Duration of Leucopenia (DL; days) –Construction Work (CW; Yes or No) –Date of diagnosis (T; year) –Type of Device (TD; none, 10(4) class, plasmer, laminar flow)

22 Methods: multivariate analysis Model –P(Occurrence of IPA) = f(TD, A, S, L, DN, DL, CW, T, ) –f: logistic link –Correlated data Use of GEE or mixed model –Correlation matrix = exchangeable Check of loglinearity –Forced variable in the model : date of diagnosis Non randomized study

23 Methods: multivariate analysis Time of diagnosis (T; year) –Continuous –Discrete Duration of leucopenia (DL; days) –Data collection not complete Listwise deletion Median imputation 3 classes : = Median, « Missing »

24 Results Univariate analysis

25 From 01/01/2000 to 07/20/2004 Probable IPA n = 20 (80%) Possible IPA n = 0 28 IPA (6.8%) 407 Aplasia AML/ALL (236 pts) From 07/20/2004 to 12/31/2007 Proven IPA n = 9 (26%) Probable IPA n = 21 (60%) Possible IPA n = 5 (14%) 35 IPA (8.7%) 391 Aplasia AML/ALL (199 pts) Proven IPA n = 8 (20%)

26 Results Baseline characteristics

27 Population under study Before Plasmairs® After Plaismairs ® P Patients Aplaisia Age55 (17-81)56 (16-86)ns AML321 (79%)303 (78%)ns ALL86 (21%)88 (22%)ns Laminar Flow sector 231 (57%)197 (50%)ns Class 10 4 Sector 90 (22%)86 (22%)ns Standart Sector Plasmairs 86 (21%) (28%) ---- IPA28 (6.8%)35 (8.7%)ns De novo IPA12/187 (6.4%)17/176 (9.6%)ns

28 Patientss characteristics (Aspergillosis) BAL: BronchoAlveolar Lavage; ME: Microscopic Examination; Asperg. Ag: Aspergillus Antigen Before Plasmairs®After Plaismairs®P Invasive Aspergillosis (IA)2835- IPA26/2833/35ns Male vs Female16 vs 1120 vs 15ns Age58 (27-76)64 (22-75) Hematol.Prog.disease13/2818/35ns Hospitalization before IA (d) 21 (8-54)21 (10-63)ns Neutropenia before IA (d)17 (11-60)18 (10-90)ns Hospitalization after IA(d)17 (2-85)15 (2-40)ns Neutropenia after IA (d)8 (0-83)8 (0-40)ns BAL + (culture or ME)9/235/29ns Asperg Ag + (in BAL)20/2320/29ns Asperg Ag + (in Sera)20/2721/35ns Pathological exam +89ns

29 Treatment and evolution of patients with aspergillosis Before Plasmairs® After Plaismairs® P Invasive Aspergillosis (IA)2835 Antifungal monotherapy5/2814/ Combination antifungal therapy 23/2821/ Associated Surgery3/283/35ns Aspergillosis response (CR+PR) 22/28 (79%)29/35(83%)ns Hematological complete response 13/28 (46%)20/35 (57%)ns Median survival (weeks)31 (1-422)34 (1-191)ns Survival at 12 weeks18/28 (64%)30/35 (86%)*0.04 Death with aspergillosis6/28 (21%)7/35 (20%)ns

30 From 01/01/2000 to 20/07/2004 (Before plasmairs®) Laminar Flow 3.9 % 9 IA / 231 Aplasia 10 4 Class 5.6 % 5 IA / 90 Aplasia Standard 16.3 % 14 IA / 86 Aplasia NS Invasive aspergillosis incidence Laminar Flow 10 4 Class >> Standard P < P = 0.03

31 From 07/20/2004 to 12/31/2007 (with plasmair®; without and then with construction work in the hospital) Laminar Flow 5.6 % 11 IA / 197 Aplasia 10 4 Class 10.5 % 9 IA / 86 Aplasia plasmair® 13.8 % 15 IA / 108 Aplasia NS Invasive aspergillosis incidence Laminar Flow > plasmer® P = 0.02 NS plasmer ® 10 4 Class

32 From 07/20/2004 to 12/31/2006 (with plasmair®; without construction work in the hospital) Laminar Flow 5.7 % 8 IA / 141 Aplasia 10 4 Class 8.5 % 5 IA / 59 Aplasia plasmair® 12.8 % 10 IA / 78 Aplasia NS Invasive aspergillosis incidence Laminar Flow > plasmer® P = 0.06 NS plasmer ® 10 4 Class

33 From 01/01/2007 to 12/31/2007 (with plasmair®; with construction work in the hospital) Laminar Flow 5.3 % 3 IA / 56 Aplasia 10 4 Class 14.8 % 4 IA / 27 Aplasia plasmair® 16.7 % 5 IA / 30 Aplasia P = NS Invasive aspergillosis incidence Laminar Flow > = plasmer® P = 0.08 P = NS plasmer ® 10 4 Class

34 Laminar Flow 5.7 % 8 IA / 141 Aplasia 10 4 Class 8.5 % 5 IA / 59 Aplasia plasmairs® 12.8 % 10 IA / 78 Aplasia All sectors 8.3 % 23 IA / 278 Aplasia From 07/20/2004 to 12/31/2006From 01/01/2007 to 12/31/2007 Impact of construction work in the university hospital During construction With plasmairs® Laminar Flow 5.3 % 3 IA / 56 Aplasia 10 4 Class 14.8 % 4 IA / 27 Aplasia plasmairs® 16.7 % 5 IA / 30 Aplasia All sectors 10.6 % 12 IA / 113 Aplasia P = NS

35 Results Multivariate analysis

36 Methods: multivariate analysis Duration of leucopenia (DL; days) –7.43 % « missing data » (1-(735/794)) –Missing At Random Sex, Type of device, API, Time, Construction Work

37 Results of the model Significant –Age (A) –Duration of Leucopenia (DL; days) –Time of diagnosis (T; year) –Type of Device (TD; none, 10(4) class, plasmer, laminar flow) Not significant –Sex (S) –Type of leukemia (L; AML or ALL) –de novo patient (DN; Yes or No) –Construction Work (CW; Yes or No)

38 Model 1 (Time continuous; logit) VariablesOdds Ratio (OR) p Duration of leucopenia Age Time (continuous) Type of device None plasmer Class 10(4) Laminar Flow Ref

39 Model 2 (Time discrete; GEE) VariablesCoefficientp Duration of leucopenia Age Time (discrete) Type of device None plasmer Class 10(4) Laminar Flow ref ref

40 Model 3 (Time discrete and duration of leucopenia with median substitution; GEE) VariablesCoefficientp Duration of leucopenia (Median substitution) Age Time (discrete) Type of device None plasmer Class 10(4) Laminar Flow ref ref

41 Model 4 (Time continuous and duration of leucopenia with 3 classes; GEE) VariablesCoefficientp Duration of leucopenia (reference : < median) Age Time (continuous) Type of device None plasmer Class 10(4) Laminar Flow ref ref

42 Discussion

43 Multivariate analysis Duration of leucopenia –Major risk factor –Missing values Effect of Plamairs remains significant under sensitivity analysis

44 Discussion What about others devices ? Example Photoclean® –http://www.photocleanquartz.com/ –Under evaluation in medical area

45 Discussion Limits of the study Randomization –It would be better for internal validity But, no randomized study available for the reference device (Laminar flow) »Humphreys H. J Hosp Infect : Power –Sample size not determined a priori IPA is a rare disease –Multicentric study needed ?

46 Discussion Limits of the study Outcome measure –Plan to take into account time to event –« Missing » values for duration of leucopenia –Only simple imputation methods used No multiple imputation or Maximum likelihood-based procedures –= > Recover the data !

47 Conclusion

48 plasmers seems to prevent IPA Results must be confirmed –« Missing values » for duration of leucopenia –Taking into account time to event

49 Thank you for your attention


Download ppt "Impact of air decontamination by use of Plasmers on the occurrence of invasive aspergillosis in patients at risk in hematological ward Aho Glélé LS**,"

Similar presentations


Ads by Google