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Approximately 10-40 of all nosocomial infections are pneumonic, taking to sculpt complication. Aged, debilitated, or critically sick patients are at high hazard. Respiratory attention equipments including ventilators, humidifiers, atomizers and processs have been identified as possible vehicle for major nosocomial infections if colonized by Fungis or bacteriums. Aim-To determine the rate of colonisation by bacteriums and Fungis in O humidifier Chamberss of portable cylinders and cardinal lines at our infirmary. The Hudson ‘s Chamberss of atomizers were besides studied for the same. Methods-Swabs from equipment were obtained utilizing unfertile swabs on Tuesday, as these Chamberss are normally cleaned on every Saturday. Topographic point samples were taken from ICUs, wards, casualty and OPD on a individual twenty-four hours. Air samples were besides obtained on the same twenty-four hours to find if the fungal spore burden in the inhaled room air was normal or high. We performed disinfection with 70 % ethyl alcohol after cleansing of these devices. Results-53/70 ( 75.71 % ) samples showed fungous growing ; out of these, 23/33 ( 69.70 % ) were from ICU, 24/30 ( 80 % ) were from wards and 6/7 ( 85.71 % ) were from OPDs. 23/30 ( 76.66 % ) swabs from cardinal line humidifiers, 18/23 ( 78.26 % ) swabs from O2 cylinder humidifier and 8/17 ( 47.5 % ) swabs from atomizers grew bacteriums. Of the entire 61 ( 87.14 % ) bacterial isolates, 42 ( 68.85 % ) were gram negative bacteriums and 19 ( 31.14 % ) were gram positive coccus. Out of 42 Gram negative bacteriums 17 were multi-drug immune i.e. ESBL manufacturers. Pseudomonas spp. ( 6 ) Acinetobacter spp. ( 4 ) , Klebseilla pneumoniae ( 4 ) , E.coli ( 2 ) , Stenotrophomonas maltophila ( 1 ) . Our determination ( before disinfection ) showed colonisation rate for Fungi was 75 % and for bacteriums it was 87 % . After 70 % ethanol disinfection and rigorous conformity of manus hygiene colonisation rates significantly reduced. Fungal colonisation rate reduced and merely 15 % fungus grew after disinfection while merely 12 % bacterial colonisation rate were determined. Conclusion-The survey indicates a possible in-hospital beginning of allergens and infection. The O and atomizer Chamberss need to be cleaned more often with germicides to command likely nosocomial infections.

Key wards- Microbial colonisation, respiratory devices, Aspergillus fumigates, Pseudomonas spp. Acinetobacter spp.

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Introduction- Respiratory infections are the commonest among the nosocomial infections. Nosocomial pneumonia is the 2nd most common nosocomial infection worldwide and the most common infection in intensive attention unit ( ICU ) . In the United States, The Center for Disease Control and bar ( CDC ) estimated approximately 1.7 million hospital-associated infections, from all type of micro-organisms, including bacteriums, Fungis, viruses lending 99,000 deceases per twelvemonth [ 1,2 ] . The National Nosocomial Infections Surveillance ( NNIS ) system study, informations summary from January 1992 through June 2004, issued in October 2004 reported a steady addition in the rate of nosocomial fungous infections, from 3.8 to 4.9 per 1,000 discharges [ 3 ] .

Progresss in medical and surgical therapy over the past two decennaries have changed the type of patients cared in the infirmaries. Care in particular units use invasive monitoring devices ; parentral nutrition, broad- spectrum antimicrobic agents and assisted airing. These have helped to successfully handle patients enduring from antecedently known to be lay waste toing or fatal diseases [ 3,4 ] . This badly sick, immunocompromized, hospitalized patient population is extremely susceptible to nosocomial infections caused by assortment of bacteriums and Fungis. The ensuing unwellness is frequently terrible, quickly progressive and hard to name or handle. Approximately 40 % of all nosocomial infections are pneumonic. Respiratory attention equipments including ventilators, humidifiers, and atomizers have been identified as possible vehicles for major nosocomial infections if these are colonized by Fungis or bacteriums. Nosocomial pathogens may besides be acquired by the custodies of infirmary forces, contaminated endovenous lines or fluids [ 5,6 ] .Potential reservoirs of pathogens doing nosocomial puneumonia include- oropharynx, windpipe, tummy, respiratory therapy equipment, paranasal fistulas, sanctuary ( above tracheal tubing turnup and below true vocal cords ) .

Contaminated respiratory attention equipment may take to nosocomial infection by two paths. First, respiratory attention equipment may function as a reservoir for micro-organism particularly Gram-negative B. The fluid incorporating devices such as atomizers and humidifiers may go to a great extent contaminated by bacteriums and fungi capable of multiplying in H2O. Pathogens may so distribute to the patient by aerosolization in the room. Second, contaminated equipment may take to direct instillment or bringing of micro-organisms to the air passages, if the equipment is straight linked to a ventilator system or if contaminated medicine is distillated aerosolised. [ 8-10 ] .Many equipments such as O mask, nebulizer Chamberss may be transferred from patient to patient several times daily but rarely cleaned day-to-day. In our institute, these equipments are routinely cleaned one time a hebdomad i.e. on Sabbatums with soap and tap H2O. We thought that these should be considered as possible beginnings of bacterial colonisation and subsequent transmittal.

Systematic surveies and studies obviously recognized that contaminated inspiration therapy equipments are the possible cause for nosocomial pneumonia but such surveies have been comparatively few. Bacteriological sampling dramas important map in set uping the success of plans intended to decrease the infection jeopardy related with inspiration therapy.

The significant clinical and fiscal impact of nosocomial pneumonia makes this an of import capable affair for infirmary epidemiologists and microbiologists. Pneumonia is associated with the greatest mortality with nosocomial infections and with well increased costs of attention. Preventive steps may cut down the incidence of nosocomial pneumonia by forestalling transmittal of extremely infective micro-organisms to patient by cut downing colonisation of reservoir site. Infection control activities should stress the constitution of appropriate preventative guidelines and policies and the go oning instruction of wellness attention workers to keep optimum conformity with preventative patterns [ 14, 15, 16 ] .

Another of import facet is an progressively common determination of fungous infections in hospital scenes. Although Fungi are by and large thought to be less infective than bacteriums to worlds, such prevalence is found to be increasing in ailment patients, particularly ICUs. The usual account given is that Fungis take the lead in infecting an immunocopmromized patient who is good covered with antibiotics. However, we thought that there may be another possible ground for such infections i.e. the fluid incorporating reclaimable respiratory attention equipments such as atomizers and O humidifiers. A thorough cognition and understanding about colonisation of respiratory devices by bacteriums and Fungis, is therefore needed for clinicians and microbiologists to supply better patient attention. Continued epidemiologic and laboratory research is required to better qualify these pathogens and therefore to better diagnosing and curative schemes in the hereafter. Hence, we aimed to qualitatively measure the microbic colonisation rate in O humidifier Chamberss ( of portable cylinders and cardinal lines ) and Hudson ‘s Chamberss of atomizers ; being used in assorted wards and ICUs of our infirmary. We besides performed a survey to find the efficaciousness of 70 % ethanol rub as decontamination of respiratory devices.

Methods- Study period- Jan 2011 to April 2011. The survey was approved by institutional reappraisal board.

Sample aggregation methods-Total of 70 swabs samples were obtained from interior surface of O humidifiers and Hudson ‘s Chamberss of atomizers utilizing unfertile swabs on a Tuesday as these Chamberss are normally cleaned on every Saturday at our institute. Topographic point samples were taken from ICUs ( 33 ) , wards ( 30 ) , casualty and OPD ( 7 ) on a individual twenty-four hours. We performed disinfection with 70 % ethyl alcohol to all supra mentioned equipment and after disinfection, we have collected swabs samples from interior surface of equipments and followed same protocol to find rate of colonisation. Air samples were besides obtained on the same twenty-four hours to find if the fungal spore burden in the inhaled room air was normal or high. Quality control-10 swabs were collected from new, fresh O humidifiers and Hudson ‘s Chamberss of atomizers as control and swabs were seeded on Sabouraud ‘s dextrose agar ( SDA ) angles with antibiotics and SDA angles without antibiotic and blood agar to look into quality control.

In order to keep the blinding, the samples from assorted sites were coded. The pulmonologist research workers collected the samples and therefore were un-blind. The microbiology research workers were blinded to the information about the site to which the swabs belonged to.

Bacteriological examination- Swabs were inoculated in glucose stock and incubated aerobically at 37EsC in brooder for 4 hour. Incubated glucose broth was so sub cultured on Mac Conkeys agar and blood agar and incubated at 37EsC nightlong. Growth after nightlong incubation were identified and confirmed by standard conventional methods.

Antibiotic susceptibleness trials – The Kirby- Bauer method recommended by the CLSI guidelines ( 2005 ) was used for antimicrobic susceptibleness proving [ 17-20 ] .

Detection of Extended Spectrum I?-Lactamases-Screening Test ( CLSI, 2010 )

Initially testing trial for ESBL production was done as portion of everyday susceptibleness proving. Two antibiotic phonograph record, Fortaz ( 30 I?g ) and Claforan ( 30 I?g ) were used for testing for ESBLs. Plates with Mueller- Hinton Agar ( MHA ) were prepared and inoculated with the trial being ( turbidness matching to 0.5 McFarland ‘s criterion ) to organize a lawn civilization. The above phonograph record were applied on the surface of the agar. The home bases were incubated at 37 ° C overnight and sensitive form and immune form were recorded by reading the zone diameter of the trial being. If a zone diameter of a‰¤ 22mm for Ceftazidime and a‰¤27 millimeter for Claforan was recorded these strain were considered “ Leery ” for ESBL production [ 20-22 ] .

Double Disk Approximation Test ( DDAT )

Bacterial suspension equivalent to 0.5 McFarland criterions turbidness for proving ESBL production trial were prepared. A unfertile swab was dipped into standardised inoculant and the besotted swab was rotated against the upper inside wall of the tubing to show extra fluid. The full surface of the MHA was swabbed to organize a lawn civilization and the inoculant was allowed to dry for a minute with palpebra in topographic point. With unfertile forceps, Ceftazidime disc was placed on the agar home base near the Centre giving a Centre to center distance of 15 millimeter Ceftazidime/clavulonic acid ( 30Aµg/10Aµg ) . The home bases were inverted and incubated at 37°C for 16-18 hours. Each home base was examined for sweetening of zone of suppression for ceftazidime disc at the side confronting Ceftazidime/clavulonic acid disc. If the strain was an ESBL manufacturer, so the zone around ceftazidime disc was extended towards Ceftazidime/clavulonic acid disc. ATCC Escherichia coli -25922 were used as negative control and ATCC K. pneumoniae -700603 was used as positive control [ 23-25 ] .

Mycological examination- Swabs were inoculated straight on Sabouraud ‘s dextrose agar ( SDA ) with and without antibiotics i.e, Chloramphenicol ( 50 mg/ml ) & A ; Gentamicin ( 20 mg/ml ) and incubated at 25A°C & A ; 37A° C individually over a period of four hebdomads. Fungus designation was done based on the growing rate, settlement morphology, contrary and obverse surface coloring material of SDA angle & A ; microscopic facets such as mycelium & A ; conidia types. Dematiaceous casts were considered when settlements that can develop dark grey to black mycelium, peculiarly outstanding when a black contrary of the settlement was observed.Species designation was done by lactophenol cotton blue ( LPCB ) of civilization positive Fungi [ 26-29 ] .

Consequences and observations-

Table 1 Distribution of swab trying from assorted sites

SWAB SAMPLES

Intensive care unit

Wards

OPD

Entire

Cardinal line humidifiers

22

8

30

O2 cylinder humidifiers

5

14

4

23

Atomizer Chamberss

6

8

3

17

Sum

33

30

7

70

Sum of 70 swab samples were processed i.e. 33 from ICUs, 30 from wards and 7 from OPD. 53/70 ( 75.71 % ) samples showed fungous growing ; out of these, 23 ( 69.70 % ) were from ICU, 24 ( 80 % ) were from wards and 6 ( 85.71 % ) were from OPDs. 23/30 ( 76.66 % ) swabs from cardinal line humidifiers, 18/23 ( 78.26 % ) swabs from O2 cylinder humidifier and 8/17 ( 47.5 % ) swabs from atomizers grew bacteriums.

Table 2 Frequency of Various Fungal Isolates in Swab Samples out of a sum of 53 positive samples

Sr. no

Name of the species

Frequency of isolation

Predominate site

Prevailing equipment

1

Aspergillus fumigatus

18 ( 33.96 % )

TB & A ; Chest OPD ( 5/18 )

SICU ( 3/18 )

PICU ( 3/18 )

Female Surgery Ward ( 2/18 )

Casualty ( 2/18 )

MICU ( 1/18 )

Male Med Ward ( 1/18 )

Male Surgery Ward ( 1/18 )

Cardinal line humidifier 10/18

O2 cylinder humidifier 6/18

Nebulizer 2/18

2

Aspergillus Niger

10 ( 18.86 % )

Pediatric Ward ( 3/10 )

PICU ( 3/10 )

Pediatric OPD ( 2/10 )

Female Medicine Ward ( 1/10 )

Surgical ICU ( 1/10 )

CentralLine Humidifiers ( 4/10 )

O2 Cylinder Humidifiers ( 4/10 )

Atomizers ( 2/10 ) *

3

Fusarium spp.

8 ( 15.09 % )

Pediatric Ward ( 3/8 )

Pediatric ICU ( 2/8 )

Female Medicine Ward ( 1/8 )

Male TB Chest Ward ( 1/8 )

Surgery OPD ( 1/8 )

Cardinal Line

Humidifiers ( 4/8 )

O2 Cylinder Humidifiers ( 3/8 )

Nebulizer ( 1/8 )

4

Alternaria spp.

7 ( 13.20 % )

Male TB Chest Ward ( 2/7 )

Surgical ICU ( 2/7 )

Female Medicine Ward ( 1/7 )

Female Surgery Ward ( 1/7 )

Surgery OPD ( 1/7 )

O2 Cylinder Humidifiers ( 5/7 )

Cardinal Line Humidifiers ( 2/7 )

5

Chaetomium spp.

5 ( 9.4 % )

Female medical specialty Ward ( 1/5 )

MICU ( 1/5 )

Male TB Chest Ward ( 1/5 )

SICU ( 1/5 )

TB & A ; Chest OPD ( 1/5 )

Cardinal Lines ( 3/10 )

Cylinders ( 1/5 )

Nebulizer ( 1/5 )

6

Aspergillus flavus

3 ( 5.6 % )

Female Medicine W ( 1/3 )

PICU ( 1/3 )

Casualty ( 1/3 )

O2 Cylinders ( 3/3 )

7

Aspergillusgalucus

3 ( 5.6 % )

MICU ( 2/3 )

Medicine OPD ( 1/3 )

O2 Cylinders ( 2/3 )

Cardinal Line ( 1/3 )

8

Chrysosporium spp.

3 ( 5.6 % )

MICU ( 1/3 )

SICU ( 1/3 )

Pediatric OPD ( 1/3 )

Cardinal Lines ( 2/3 )

O2 Cylinders ( 1/3 )

9

Streptomycess spp.

3 ( 5.6 % )

SICU ( 2/3 )

TB & A ; Chest OPD ( 1/3 )

Cardinal Line ( 1/3 )

O2 humidifiers ( 1/3 )

Atomizers ( 1/3 )

10

Candida spp.

2 ( 3.7 % )

Casualty ( 1/2 )

MICU ( 1/2 )

Cardinal Line ( 1/2 )

Atomizers ( 1/2 )

11

Trichoderma spp.

2 ( 3.7 % )

MICU ( 2/2 )

Cardinal Line ( 2/2 )

12

Penicillium spp.

2 ( 3.7 % )

MICU ( 2/2 )

Cardinal Line ( 2/2 )

14

Curvularia spp.

1 ( 1.8 % )

MICU ( 1/2 )

Cardinal Line ( 1/2 )

NICU – neonatal intensive attention unit, PICU – paediatric intensive attention unit, MICU – medical specialty intensive attention unit, SICU – surgical intensive attention unit, O2 -oxygen, OPD – out door patients.

Of the 51 ( 75.71 % ) entire fungous isolates, Aspergillus fumigatus 18 ( 33.96 % ) were preponderantly isolated followed by Aspergillus niger10 ( 18.86 % ) .

Table 3 Frequency of Various bacterial Isolates in Swab Samples out of a sum of 61 positive samples

Sr. no.

Name of bacteriums

Frequency of isolation

Predominate site

Prevailing equipment

1

Pseudomonas spp.

15

MICU ( 5/15 )

SICU ( 5/15 )

PICU ( 3/15 )

OPD ( 2/15 )

Cardinal Line ( 3/15 )

O2 humidifiers ( 8/3 )

Atomizers ( 4/3 )

2

Acinetobacter spp.

10

MICU ( 4/2 )

PICU ( 4/10 )

SICU ( 1/3 )

OPD ( 1/3 )

Cardinal Line ( 4/10 )

O2 humidifiers ( 4/10 )

Atomizers ( 2/10 )

3

E. coli

8

PICU ( 4/8 )

MICU ( 2/8 )

SICU ( 1/8 )

OPD ( 1/8 )

Atomizers ( 4/8 )

Cardinal Line ( 3/8 )

O2 humidifiers ( 1/8 )

4

Klebseilla spp.

7

PICU ( 4/7 )

SICU ( 1/7 )

MPICU ( 1/7 )

OPD ( 1/7 )

Atomizers ( 4/7 )

Cardinal Line ( 2/7 )

O2 humidifiers ( 1/7 )

5

Methicillin immune Staphylococcus aureus ( MRSA )

5

MICU ( 2/5 )

PICU ( 1/5 )

SICU ( 1/5 )

OPD ( 1/5 )

Atomizers ( 2/5 )

Cardinal Line ( 2/5 )

O2 humidifiers ( 1/5 )

6

Methicilin sensitive staphylococci aureus ( MSSA )

6

MICU ( 2/6 )

SICU ( 2/6 )

PICU ( 1/6 )

OPD ( 1/6 )

Atomizers ( 3/6 )

Cardinal Line ( 2/6 )

O2 humidifiers ( 1/6 )

7

Coagulase negative Staphylococcus aureus ( CONS )

8

PICU ( 4/8 )

MICU ( 2/8 )

OPD ( 1/8 )

S ICU ( 1/8 )

Cardinal Line ( 4/10 )

O2 humidifiers ( 4/10 )

Atomizers ( 2/10 )

8

Stenotrophomonasmaltophila

2

SICU ( 1/2 )

PICU ( 1/2 )

Cardinal Line ( 1/2 )

O2 humidifiers ( 1/2 )

NICU-neonatal intensive attention unit, PICU- paediatric intensive attention unit, MICU- medical specialty intensive attention unit, SICU- surgical intensive attention unit, O2 -oxygen, OPD- out door patients.

Of the entire 61 ( 87.14 % ) bacterial isolates, 42 ( 68.85 % ) were gram negative bacteriums and 19 ( 31.14 % ) were gram positive coccus. Out of 42 Gram negative bacteriums 17 were multi-drug immune i.e. ESBL manufacturer. Pseudomonas spp. ( 6 ) Acinetobacter spp. ( 4 ) , Klebseilla pneumoniae ( 4 ) , E.coli ( 2 ) , Stenotrpphomonas maltophila ( 1 ) .

Discussion-

One tierce of nosocomial infections are considered preventable. Information sing the possible hazard of transmittal due to colonisation of respiratory equipment/devices is deficient. Aspergillus spp. is omnipresent, normally happening in dirt, H2O, and disintegrating flora. Potential reservoirs in infirmaries may include unfiltered air, airing systems, O humidifiers, atomizer Chamberss and tubing ‘s, contaminated dust dislodged during hospital building, rug, nutrient and cosmetic workss [ 30 ] . Aspergillus fumigatus, A. flavus, A. terreus have become common cause of nosocomial infections. Contaminated air or airing systems have been associated repeatedly with eruptions of nosocomial brooder pneumonia [ 31 ] . Construction and destruction activity nearby infirmary, redevelopment, cleansings and moist environment within the airing system or air filter have been normally cited. During our survey period, our hospital building work was in advancement and it is a likely ground for isolation of Aspergillus spp. in higher proportion.

Hyalohyphomycosis i.e. non dematiaceous casts have late been recognized as emerging nosocomial pathogens [ 32 ] . Our survey happening showed colonisation by Fusarium spp. in 8 ( 15.09 % ) swabs samples chiefly from humidifiers. The mechanism of infection may include inspiration into the lungs or upper air passages or interruptions in the tegument or mucose membranes.

The patients hospitalized with aggravations of clogging airway disease such as asthma frequently require nebulization and O therapy. If the O humidifier Chamberss or the nebulizer Chamberss are colonized by Fungis, the clinician may really be straight presenting the fungous allergen to the patient ‘s air passages. Rather, we suspect that this may be the cause for an occasional delayed response to asthma therapy.

Finding Fungi or barm cells in the phlegm of patients having corticoid or antibiotic therapy is non uncommon. A survey showed that Fungi may be found in phlegm in 42.4 % of patients having anterior antibiotics and 64.2 % of patients having prior inhaled steroids [ 33 ] . Majority of nosocomial infections are caused by Candida spp. [ 34 ] . In our survey, Candida tropicalis were isolated from two cardinal line atomizers. There are several studies on turning prevalence of non-albicans Candida among hospitalized patients [ 36-37 ] . Cross-infection from staff to patient may be common, even in ICU. Rangel-Frausto et.al reported that custodies of wellness attention workers were reservoir for Candida spp. and 85 % were non- albicans Candida [ 34 ] . An eruption of Candida tropicalis fungemia in neonatal intensive attention unit ( NICU ) was reported in newborns who were having entire parenteral nutrition and antimicrobic agents [ 37, 38 ] . Same survey showed that Candida tropicalis was isolated from two NICU workers and non from environment. Washing custodies as quickly and exhaustively as possible between patient contacts and after contact with blood, organic structure fluids, secernments, eliminations, equipment or articles contaminated by them is an of import agencies of infection control and isolation safety steps.

The etiology of bacterial nosocomial pneumonia depends on continuance of hospitalization before pneumonia develops. Early oncoming nosocomial pneumonia is the happening during the first four or five yearss of the infirmary stay. It is more normally caused by community acquired pathogens such as Streptococcus pneumoniae, Methicillin-susceptible Staphylococcus aureus, H. grippe, Morexella catahalis [ 39 ] . In contrast, late onset nosocomial pneumonia ( which normally happening after five to six yearss of hospitalization ) is normally caused by Pseudomonas aeruginosa, Acinetobacter spp. , Methicilline resistant Staphylococcus aureus etc. [ 40- ] . After 10 or more yearss in infirmary, Enterobacteriaceae and P. aeruginosaare the most common pathogens responsible [ 41 ] . Several surveies have reported the etiology of nosocomial pneumonia in the long-run attention scenes [ 42-45 ] . Present survey showed high colonisation rate by Pseudomonas spp. and Acinetobacter spp. followed by E. coli and Klebseilla spp. Klebseilla pneumoniae had been associated with 2 % -5 % of nosocomial infections, peculiarly from lower respiratory and urinary piece of lands. Nosocomial eruptions by gram negative bacteriums were associated with their drug opposition to third-generation Mefoxins and aminoglycosides [ 1-4 ] . Present survey showed entire 17/61 ( 27.86 % ) extended spectrum I?-lactamases ( ESBL ) species.

We performed disinfection with 70 % ethyl alcohol after cleansing of these devices ( O humidifiers and nebulizer Chamberss with distilled H2O and soap. Health attention workers were educated for manus hygiene with alcohol-based manus hang-ups before and after each patient contact. We collected swabs once more from same wards and ICUs after 70 % ethanol disinfection and determined colonisation rate by same methodological analysis. Our determination ( before disinfection ) showed colonisation rate for Fungi was 75 % and for bacteriums it was 87 % . After 70 % ethanol disinfection and rigorous conformity of manus hygiene colonisation rates significantly reduced. Fungal colonisation rate reduced and merely 15 % fungus grew after disinfection while merely 12 % bacterial colonisation rate were determined.

Restriction of this nowadayss survey is that we have non taken in to consideration any taint with viruses or Mycobacteria. This is because prevalence of nosocomial viral or Mycobacterial infection is really really low. We have assessed merely 70 % ethyl alcohol wipe disinfection was and have non compared the consequences with other high degree germicide ; the ground being the cost of the assorted disinfecting agents and the practicableness of their usage.

Conclusion-

We consider it to be prudent to execute periodic surveillance for bacterial and fungous colonisation in the respiratory equipment, peculiarly water-sealed devices. Proper cleansing and sterilisation or high degree disinfection of reclaimable equipment is indispensable to forestall infections associated with respiratory therapy such as O therapy, nebulization etc. Devicess or parts of devices need to be rinsed in H2O after they have been chemically disinfected. Sterile H2O has been recommended because pat or locally prepared distilled H2O may harbour micro-organisms that can potentially do pneumonia. The execution of new and regular hygiene steps for the care of such equipment is desirable.

Acknowledgement- Part of the information was presented in European Respiratory Society ( ERS ) – Dutch capital 2011 under rubric ” Fungal Colonization of Oxygen Humidifier and Nebulizer Chambers ” . The paper was awarded by Erbiums with ”silver sponsorship award ” for easing the presentation at ERS conference. The award was purely based on scientific content. The abstract has been published ERJ addendum 2011and ERJ has no expostulation to print a full paper including this information. The correspondence in this respect is uploaded herewith.

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