Though the risk of healthcare workers becoming infected is low, employee health professionals should be aware of an emerging multidrug-resistant fungus that is causing high mortality in hospital outbreaks.
Candida auris is emerging globally, spreading more like a bacterial “superbug” than fungi, the CDC reports. C. auris causes high mortality in frail patients, can transmit to patients on the hands of healthcare workers, persist in the environment, and can colonize people who then serve as a reservoir for outbreaks. As of May 12, 2017, a total of 77 cases of C. auris had been reported in seven states: New York (53); New Jersey (16); Illinois (four); and one each in Indiana, Maryland, Massachusetts, and Oklahoma.1
“The risk of C. auris infection to otherwise healthy people, including healthcare workers, is very low,” the CDC reports.2 “In the United States, C. auris infection has primarily been identified in people with serious underlying medical conditions who have had prolonged admissions to healthcare settings or reside in healthcare settings. Otherwise healthy people do not seem to be at risk for C. auris infections, but can be colonized on their skin. In one study involving a C. auris outbreak, colonization with C. auris was detected in <1% of healthcare workers. Protect yourself and your patients by cleaning your hands.”
Healthcare workers should not be tested for C. auris unless they are identified as a possible source of transmission to patients, the CDC recommends. Likewise, family members of healthcare workers do not need to be tested for C. auris, the CDC notes.
CDC Recommendations
The CDC is working with both state and local partners to create and distribute infection control recommendations to curb the spread of C. auris. The CDC’s current recommendations for C. auris-colonized or infected patients include:
- use standard precautions and contact precautions;
- place the patient in a private room;
- notify receiving healthcare facilities when a patient with C. auris colonization or infection is transferred;
- perform daily and terminal cleaning of the patient’s room with a disinfectant active against Clostridium difficile spores.
“We found that it [C. auris] exists in the environment in very high concentrations on beds and things closest to patients,” says Paige Armstrong, MD, a CDC officer in the Epidemic Intelligence Service (EIS). “[It’s] even in the crevices and the corners of the room, meaning that we really need to focus on cleaning with the right [disinfectants] to kill this organism.”
Armstrong was among several CDC investigators who reported on outbreaks of C. auris recently in Atlanta at the annual EIS conference.
“It has colonized people even after they were treated with antifungal medications — people still have it on their skin,” she says. “This is something that we don’t usually see with a fungus. These are things that we typically see with emerging or resistant bacteria.”
As has been demonstrated with multiple pathogens, the ability to persist in a colonized state means patients with no symptoms of infection could serve as a reservoir for spread to vulnerable patient populations, particularly those on IVs and other invasive devices that could seed bloodstream infections. C. auris has caused high mortality in outbreaks that involved bloodstream infections.
In addition, C. auris has the ability to develop resistance that is “very rare” in fungi, she says.
“There are only three main classes of antifungal medication,” Armstrong says. “So once you become resistant to all three of those, there’s very little that can be done. It’s causing outbreaks in hospitals, which again, is something we typically attribute to bacteria. This is an emerging multidrug-resistant fungus that is acting like a bacterium — it’s acting like a superbug.”
High Fatality Outbreak
Evidence of the devastation possible by C. auris as a healthcare-associated infection (HAI) was demonstrated in an outbreak in several neonatal ICUs in hospitals in Colombia in 2016. Armstrong was the lead CDC investigator and reported the findings at the EIS conference.
“We’re talking about babies that have just been born, at times premature, so some of the most vulnerable patients,” Armstrong says. “When we got word of this and heard that it was very difficult to contain [and] curtail, we immediately responded and went down to Colombia.”
Working with investigators from the Instituto Nacional de Salud, Colombia’s CDC equivalent, Armstrong and colleagues visited four hospitals in three different cities. They identified 40 cases of C. auris, and more than half of them died. The in-hospital mortality rate was 56%. Forty-five percent of patients were infants. All patients had a central venous catheter, two-thirds had recent surgery, and half received parenteral nutrition during their stay, she reported.3 C. auris was isolated from 44 (14%) of 325 environmental samples, including some from rooms that had not had a case-patient present for up to six months. Of the six patients sampled, C. auris was cultured from either the groin or axilla of four.
Another troubling finding was that two nurses’ hands yielded C. auris, suggesting the route of transmission was transient colonization via healthcare workers from other patients or equipment and environmental surfaces.
“In Colombia, we were able to establish key fundamental pieces of information about this new emerging fungus,” Armstrong says. “Those tell us that we really need to be careful about basic things like hand hygiene, making sure [healthcare workers] that are touching one person that might have this fungus on them aren’t going on and touching someone [else] to potentially spread it. I think there’s probably more than one reservoir within the healthcare setting.”
REFERENCES
- CDC. Notes from the Field: Ongoing Transmission of Candida auris in Health Care Facilities — United States, June 2016–May 2017. MMWR 2017;66(19):514–515.
- CDC. Candida auris Questions and Answers for Healthcare Workers. May 12, 2017. http://bit.ly/2qHjA5x.
- Armstrong P, Escandon DH, Caceres N. Hospital-Associated Outbreaks of Multidrug-Resistant Candida auris — Multiple Cities, Colombia, 2016. CDC EIS Conference. Atlanta, April 24-27, 2017.
Though the risk of healthcare workers becoming infected is low, employee health professionals should be aware of an emerging multidrug-resistant fungus that is causing high mortality in hospital outbreaks.
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