Importation, Mitigation, and Genomic Epidemiology of Candida auris at a Large Teaching Hospital

Abstract

OBJECTIVE Candida auris (CA) is an emerging multidrug-resistant pathogen associated with increased mortality. The environment may play a role, but transmission dynamics remain poorly understood. We sought to limit environmental and patient CA contamination following a sustained unsuspected exposure. DESIGN Quasi-experimental observation. SETTING A 528-bed teaching hospital. PATIENTS The index case patient and 17 collocated ward mates. INTERVENTION Immediately after confirmation of CA in the bloodstream and urine of a patient admitted 6 days previously, active surveillance, enhanced transmission-based precautions, environmental cleaning with peracetic acid-hydrogen peroxide and ultraviolet light, and patient relocation were undertaken. Pre-existing agreements and foundational relationships among internal multidisciplinary teams and external partners were leveraged to bolster detection and mitigation efforts and to provide genomic epidemiology. RESULTS Candida auris was isolated from 3 of 132 surface samples on days 8, 9, and 15 of ward occupancy, and from no patient samples (0 of 48). Environmental and patient isolates were genetically identical (4-8 single-nucleotide polymorphisms [SNPs]) and most closely related to the 2013 India CA-6684 strain (~200 SNPs), supporting the epidemiological hypothesis that the source of environmental contamination was the index case patient, who probably acquired the South Asian strain from another New York hospital. All isolates contained a mutation associated with azole resistance (K163R) found in the India 2105 VPCI strain but not in CA-6684. The index patient remained colonized until death. No surfaces were CA-positive 1 month later. CONCLUSION Compared to previous descriptions, CA dissemination was minimal. Immediate access to rapid CA diagnostics facilitates early containment strategies and outbreak investigations. Infect Control Hosp Epidemiol 2018;39:53-57.

Candida auris: The recent emergence of a multidrug-resistant fungal pathogen

“…Removal of catheters and lines and surgical debridement have been used alongside antifungal drugs when clinically indicated. 5,8,15,30,61,69,70…”

“…1,6,8,30,47,61,62 Patients with C. auris infection often have catheters, tracheostomies, gastrostomy tubes, total parenteral nutrition, or other invasive devices. 8,12,15,30,47,48,62,70,71 Most patients with C. auris infection in the United States have had extensive exposure to healthcare in the months preceding the C. auris infection, particularly in higher acuity longterm care facilities, such as long-term acute care hospitals and skilled nursing facilities that support patients who are chronically ventilator dependent. 14 Exposure to long-term care facilities has been a known risk factor for acquiring several bacterial MDROs, such as CRE; 72 in contrast, other Candida infections have historically been in associated with care in intensive care units.…”

Increasing prevalence, molecular characterization and antifungal drug susceptibility of serial Candida auris isolates in Kuwait

“…Candida auris is a persistent colonizer and difficult to eradicate from the hospital environment [ 4 , 6 , 39 , 45 ]. Its ability to form biofilms on a variety of surfaces and lack of activity of some antifungal agents such as fluconazole against C .…”

The comparative efficacy of antiseptics against Candida auris biofilms

“…This study however investigated suspension testing, therefore the effectiveness of this combination against adherent C. auris cells remains unknown. Furthermore, patients can remain colonised even following antifungal exposure, with C. auris isolated from skin and urine postprolonged echinocandin therapy [17]. Given the propensity of C. auris to form biofilms [11], and its isolation from catheter tips [1,18], skin decolonisation prior to invasive therapy could be considerered.…”