Mary Madison, RN, RAC-CT, CDP
Clinical Consultant – Briggs Healthcare
Candida auris (C. auris) has been on the infectious disease community’s radar for a few years now. This emerging fungus (yeast) presents a serious global health threat. CDC is concerned about C. auris for these three main reasons (bolding added by me):
- It is often multidrug-resistant, meaning that it is resistant to multiple antifungal drugs commonly used to treat Candida infections.
- It is difficult to identify with standard laboratory methods, and it can be misidentified in labs without specific technology. Misidentification may lead to inappropriate management.
- It has caused outbreaks in healthcare settings. For this reason, it is important to quickly identify C. auris in a hospitalized patient so that healthcare facilities can take special precautions to stop its spread.
The last bullet above was brought full frontal into the spotlight a couple of days ago when a New York Times piece added to their ongoing coverage of this threat by making the state of New York the first state to release the names of the medical facilities that have treated patients with Candida auris. (The identification of the names of these facilities is a topic for more thought and another discussion. In the NY Times piece, it is noted that “New York health officials said they decided to break with that practice and disclose the names of the institutions with cases in the state over the past three years because of how rapidly C. auris has spread. Their aim, they said, was to provide transparency to consumers and encourage hospitals and nursing homes to help stop its spread.”) The NY Times piece was posted on the same day the 155-page New York State Department of Health report was released.
Last October (2018) the Journal of Emerging Infectious Diseases posted a report that showed identified:
- An outbreak during 2013–2017 of 51 clinical case-patients and 61 screening case-patients interconnected by healthcare facilities throughout New York City;
- Of the 51 clinical case-patients, 23 (45%) died within 90 days and isolates were resistant to fluconazole for 50 (98%);
- Screening cultures performed for 572 persons (1,136 total cultures), results were C. auris positive for 61 (11%) persons and
- Environmental cultures were positive for samples from 15 of 20 facilities. Colonization was frequently identified during contact investigations; environmental contamination was also common.
This report is stunning. In the Discussion area, it is noted that “this large, citywide, multiple-institution outbreak of C. auris infections is ongoing. As of February 2018, most confirmed clinical cases in the United States had been identified in New York, and case numbers continue to grow. The reasons for the preponderance of cases in New York are unknown; possibilities include a true higher prevalence from multiple introductions into this international port of entry, more complete detection from aggressive case finding, presence of a large interconnected network of healthcare facilities in NYC, or a combination of all 3 factors.” Other points discussed in this report include:
- The clinical cases in the New York outbreak are similar to clinical cases described elsewhere. Fungemia is a commonly reported clinical infection; 76% of infections reported in a series from Colombia (9) and 58% in a series from India (4) were bloodstream infections. These percentages are comparable to the findings from this New York series in which 61% of initial clinical isolates were from blood. Among medically fragile patients in NYC who had a history of extensive contact with healthcare facilities, clinicians should include C. auris in the differential diagnosis for patients with symptoms compatible with bloodstream infection.
- The prospect of an endemic or epidemic multidrug-resistant yeast in US healthcare facilities is troubling.
- Transmission is ongoing in healthcare facilities, primarily among patients with extensive healthcare exposures. C. auris has been cultured from rooms and equipment in multiple facilities, and close contacts of case-patients have become colonized. Infection control lapses have probably amplified this process.
- Factors that contribute to transmission may include prolonged colonization of clinical and screening case-patients and environmental contamination. Persistent colonization of affected persons and the lack of an accepted decolonization regimen result in a large reservoir of persons carrying the organism.
- auris can remain viable on inanimate surfaces for long periods, necessitating scrupulous environmental cleaning and disinfection. Affected patients frequently have extensive contact with multiple healthcare facilities, highlighting the value of careful and thorough communication at transfer.
The CDC has critical resources to guide all healthcare professionals, patients and families, researchers and industry professionals with this very serious global health threat. A Fact Sheet provides quick information on C. auris.
These reports should be reviewed very carefully with the IDT team in your facility and most specifically by the Infection Prevention and Control as well as the QAPI committees. The threat of C. auris needs to be taken seriously by all healthcare sectors. I’ll leave you today with this excerpt from the NY Times piece:
“A lot of progress has been made but the bottom line is that antimicrobial resistance is worse than we previously thought,” said Michael Craig, the senior adviser on antibiotic resistance for the Centers for Disease Control and Prevention, which released the updated death toll on Wednesday. “Every 11 seconds someone in the United States gets a resistant infection and someone dies every 15 minutes.”