Characteristics and Management of Candidaemia Episodes in an Established Candida auris Outbreak

Abstract

The multi-resistant yeast Candida auris has become a global public health threat because of its ease to persist and spread in clinical environments, especially in intensive care units. One of the most severe manifestations of invasive candidiasis is candidaemia, whose epidemiology has evolved to more resistant non-albicansCandida species, such as C. auris. It is crucial to establish infection control policies in order to control an outbreak due to nosocomial pathogens, including the implementation of screening colonisation studies. We describe here our experience in managing a C. auris outbreak lasting more than two and a half years which, despite our efforts in establishing control measures and surveillance, is still ongoing. A total of 287 colonised patients and 47 blood stream infections (candidaemia) have been detected to date. The epidemiology of those patients with candidaemia and the susceptibility of C. auris isolates are also reported. Thirty-five patients with candidaemia (74.5%) were also previously colonised. Forty-three patients (91.5%) were hospitalised (61.7%) or had been hospitalised (29.8%) in the ICU before developing candidaemia. Antifungal therapy for candidaemia consisted of echinocandins in monotherapy or in combination with amphotericin B or isavuconazole. The most common underlying disease was abdominal surgery (29.8%). The thirty-day mortality rate was 23.4% and two cases of endophtalmitis due to C. auris were found. All isolates were resistant to fluconazole and susceptible to echinocandins and amphotericin B. One isolate became resistant to echinocandins two months after the first isolate. Although there are no established clinical breakpoints, minimum inhibitory concentrations for isavuconazole were low (≤ 1 μg/mL).

Molecular Epidemiology of Candida Auris Outbreak in a Major Secondary-Care Hospital in Kuwait

“…C. auris has previously been isolated with increasing frequency from Kuwait [ 14 , 45 ] and other Middle Eastern countries [ 22 ], and outbreaks have also been reported recently from two other (Oman and Saudi Arabia) nearby countries [ 21 , 40 , 41 ]. These reports together with our study and various outbreaks reported recently from other geographical locations [ 3 , 6 , 21 , 30 , 33 , 36 , 37 , 38 , 39 , 40 ] strongly support the emerging role of C. auris as a major cause of invasive infections and outbreaks in health care facilities worldwide that have been difficult to control. C. auris has presumably assumed this role due to several unique characteristics.…”

“…Only 17 of 71 (24%) patients affected by the C. auris outbreak in our hospital developed candidemia. The data analyses from previous C. auris outbreaks have also shown that only a fraction (~14% to 40%) of affected patients develop candidemia [ 21 , 30 , 32 , 36 , 40 ]. The risk factors for invasive C. auris infections are similar to those for other Candida spp.…”

“…However, none of the deaths were directly attributable to C. auris infection, and use of echinocandins did not reduce skin colonization. Highly variable crude mortality rates, varying from 0% to 72%, have been observed among C. auris -infected patients, likely reflecting the highly variable patient populations in different settings with different degrees of comorbidities, particularly for ICU patients and the susceptibility patterns of infecting strains [ 6 , 19 , 21 , 29 , 30 , 31 , 32 , 36 , 40 , 41 ].…”

“…Although in the beginning only sporadic cases of invasive infections due to C. auris were detected soon after its recognition as a bloodstream pathogen, nosocomial outbreaks are now being reported with increasing frequency and involving larger patient cohorts [ 10 , 11 , 28 , 31 ]. C. auris mini/major outbreaks have been reported from the United Kingdom [ 32 , 33 ], United States of America [ 34 , 35 ], India [ 12 , 16 , 25 ], Spain [ 6 , 30 , 36 ], South Africa [ 13 ], Colombia [ 37 ], Kenya [ 38 ], Russia [ 39 ], Saudi Arabia [ 40 ] and Oman [ 21 , 41 ]. Here we describe molecular epidemiology of a nosocomial outbreak which started in the high dependency unit (HDU) of a secondary-care hospital (Farwaniya Hospital) in Kuwait with genetically identical clinical and environmental C. auris isolates.…”

Candida auris: Epidemiology, Diagnosis, Pathogenesis, Antifungal Susceptibility, and Infection Control Measures to Combat the Spread of Infections in Healthcare Facilities

“…Studies have shown that once C. auris is introduced into a healthcare facility, it spreads rapidly among susceptible patients [ 40 , 41 ]. Thus far, C. auris outbreaks have been reported from the United States of America [ 42 , 43 , 44 , 45 ], Canada [ 46 ], Mexico [ 47 ], the United Kingdom [ 48 , 49 ], Spain [ 50 , 51 ], India [ 40 , 52 ], Pakistan [ 53 ], Russia [ 54 ], Saudi Arabia [ 55 ], Oman [ 56 , 57 ], Kuwait [ 58 ], Kenya [ 59 ], South Africa [ 60 ], and Colombia [ 61 ]. Studies describing single/multiple invasive infections and outbreaks in different countries or geographical locations in the last several years have been extensively reviewed, only some of which are cited here [ 29 , 30 , 31 , 32 , 38 ].…”