Large Cluster of Fluconazole-Resistant Candida auris Found

Janis C. Kelly

September 17, 2018

An ongoing outbreak of fluconazole-resistant Candida auris in healthcare facilities may be linked to improper infection control procedures, according to a report published online September 12 in Emerging Infectious Diseases.

Eleanor Adams, MD, MPH, supervisor of the Healthcare Epidemiology and Infection Control Program, Metropolitan Area Regional Office, New York State, and colleagues write that New York City has more cases of fluconazole-resistant C auris than any other US city, transmission is ongoing, and 90-day mortality may approach 45% in some populations.

Adams oversees outbreak investigations in healthcare facilities in New York City, Long Island, and the Lower Hudson Valley. She told Medscape Medical News that C auris is behaving in ways not previously observed in Candida species by becoming resistant to fluconazole and by long-term asymptomatic colonization of some persons.

"Emerging Organism"

Adams said, "This is an emerging organism. The thought of a fungus acting in ways we associate with multidrug-resistant bacteria is a novel idea, but that is what we are dealing with. To have such a great number of cases with a fungus resistant to fluconazole is a new situation in New York, and also for the nation."

The researchers identified 51 clinical case-patients from hospitals in Brooklyn (n = 21), hospitals and a medical office in Queens (n = 16), hospitals and a long-term acute care hospital in Manhattan (n = 12), and a hospital in the Bronx (n = 1), plus one patient in a western New York hospital who had previously been admitted to an involved Brooklyn hospital.

Of the clinical cases, 61% had lived in long-term care facilities just before being admitted to the hospital, and 19 of those 31 patients had been in skilled nursing facilities with ventilator beds.

Median age of the clinical cases was 72 years. All had serious concurrent medical conditions, with many requiring mechanical ventilation, central venous catheters, or gastrostomy tubes.

Mortality was high: Of the 51 clinical case-patients, 23 (45%) died within 90 days and 27% died within 30 days.

Adams said, "We found mortality of 45% within 90 days, but we could not attribute that definitively to C auris. These were for the most part very ill individuals with complex underlying medical conditions. We don't yet have a comparison group to determine whether this mortality was unique to C auris in that population."

Environmental Contamination Likely

Cultures were positive for environmental samples from 15 of 20 facilities. The authors write, "Contamination of surfaces and objects in case-patients' rooms and mobile equipment outside the rooms was common. High-yield items included bedrails, [intravenous] poles, beds, privacy and window curtains, windows, and floors."

This finding assumed particular importance because a previously published study reported the stubborn fungus can remain viable on plastic surfaces such as those in healthcare settings for 14 days.

Adams said, "We cannot definitively say that C auris was spread through contact or from environmental contamination. We don't yet have the direct proof. I do think that the evidence points in that direction."

In caring for patients infected with or colonized by C auris, the Centers for Disease Control and Prevention (CDC) now recommends using cleaning products effective against Clostridium difficile spores. Adams noted that this is an important change from the quarternary ammonium compounds routinely used in nursing homes and other healthcare settings.

Infection Control Practices Need Improvement, STAT

The researchers found that infection control precautions at facilities with C auris outbreaks were "variable." Hand hygiene was a recurrent problem, particularly access to alcohol-based hand sanitizers. Improper use of personal protection equipment (PPE) included gowns not covering shoulders or not being tied, and lack of PPE availability. The authors report, "In 1 [long-term care facility], PPE was locked in a closet; in another, the PPE carts were empty and staff were unable to locate supplies to replenish them; in a third, aprons were used instead of gowns."

Another common problem was lack of informational signs. The authors report, "One facility had no signs or other effective systems to identify persons around whom contact precautions should be taken. Compliance with signs that consisted only of instructions to see the nurse before entering was poor."

The New York State Department of Health (NYSDOH) responded to this situation by conducting educational webinars plus onsite infection control-focused reviews of all non-Veterans Affairs hospitals and long-term care facilities in Brooklyn and Queens. The NYSDOH also maintains a web page on C auris, with sections for the public and for clinicians.

Adams said that the spread of fluconazole-resistant C auris in the United States is possible, but that large clusters of cases have not been seen except in New York, New Jersey, and Illinois. She said that emergence of the fungal cases first in New York City likely reflects that area's role in international travel.

The possibility that C auris could spread to other areas is why both the NYSDOH and the CDC are alerting clinicians, healthcare facilities, and clinical laboratories to the importance of maintaining meticulous infection control practices in caring for patients infected or colonized by C auris and to obtain further testing of specimens from patients with candidemia attributed to "unknown" Candida species or to Candida haemulonii.

C auris Colonization

Another surprise was that C auris can colonize individuals for extended periods. "When we did point prevalence studies and screened uninfected persons who resided in facilities with C auris outbreaks, we found a significant number who were colonized in their skin and/or nares but had no signs or symptoms," Adams said. "There is no decolonization regimen currently recommended by CDC or other groups for these individuals, but this is an area of current investigation."

Don't Miss the Diagnosis of C auris

Correct diagnosis depends on laboratory methods able to differentiate C auris from other Candida spp. The challenge is that C auris can be mistakenly labelled "unknown Candida spp" or misidentified as C haemulonii or other species, depending on type of laboratory identification system.

In a patient with candidemia, a report including any of these is a red flag indicating that sample should be sent to NYSDOH public health laboratory at the Wadsworth Center for additional testing, Adams said.

Treating C auris Infection

Nearly all the C auris isolates from clinical cases (98%) were resistant to fluconazole, and 25% were resistant to fluconazole and to amphotericin. None of the isolates was initially resistant to echinocandins, but three patients developed resistance after echinocandin treatment.

"Based on the limited data available to date, echinocandins are currently recommended as initial therapy for treatment of C auris infections," Adams said.

NYS physicians also are asked to report all cases of C auris to the NYSDOH or to their county health department.

The authors have disclosed no relevant financial relationships.

Emerg Infect Dis. Published online September 12, 2018. Full text

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