C. auris: Active Screening Interrupts Transmission
Eighty percent of colonized patients not indicated for isolation
September 1, 2023 5 minutes read
“How can we control C. auris from coming into our inpatient healthcare facilities?” asked Julie Paoline, MA, CPHA, CIC, FAPIC, an epidemiologist at the Pennsylvania Department of Health in Harrisburg.
Active surveillance of incoming patients was the answer at two short-term acute care hospitals that agreed to participate in the project, Paoline said at the 2023 conference of the Association for Professionals in Infection Control and Epidemiology (APIC).
Overall, 80% of the incoming patients who screened positive for C. auris were not indicated for contact isolation on admission. “This admission screening project prevented multiple introductions, not only to the [two hospitals] but also to other healthcare facilities in the region, especially when you consider how these very sick patients can move between different levels of care, even within a short period of time,” she said. “I can tell you, as someone who responds to C. auris cases in my state, that on average, [these patients] have been in between two and five different healthcare facilities within the last 30 days.”
The Centers for Disease Control and Prevention (CDC) reported earlier in 2023 that C. auris had spread to about half of the states and there was “ongoing transmission within and across healthcare facilities connected via patient transfers. Healthcare transmission is responsible for most, if not all, cases.”1
The CDC reported that clinical infections increased 59% in 2020, then nearly doubled in 2021 with a 95% jump. Although there have been outbreaks in acute care hospitals, most of the C. auris cases are in high-acuity post-acute care facilities, specifically long-term acute care (LTAC) hospitals and ventilator-capable skilled-nursing facilities (vSNFs). Some hospitals have put in protocols calling for colonization screening on all patients being admitted from nursing homes. (See Hospital Infection Control Infection & Prevention, May 2023.)
The turnaround time for colonization results is somewhat resource- and laboratory-access dependent, but one study reported colonization results within 48 hours of polymerase chain reaction testing.2 The isolates in the Pennsylvania project had to be sent off to a regional lab in Baltimore, MD, and results sometimes were delayed, Paoline said.
“We are currently working with our state public health laboratory to get them on board to conduct this type of testing,” she said. “But, currently, that capacity is not there.”
In any case, patients screened for C. auris colonization should be put in empiric isolation with contact precautions until the results of testing are known, she said. There is no established decolonization protocol.
As evidence of increasing cases and spread across the health continuum became clear in the state, Paoline and colleagues did a pilot study on the efficacy of active surveillance for C. auris from March 2022 to March 2023.
The two hospitals implementing the measures had strong infection control programs targeted at C. auris, but neither had implemented active surveillance. Those targeted for screening in the study included patients who required mechanical ventilation or had a tracheostomy and were admitted from facilities where transmission has occurred, particularly LTACs and skilled nursing facilities that provide ventilator care.
Seeking Buy-In, EMR Advice
The hospitals met with public health officials for screening guidance and an in-house multidisciplinary team to promote buy-in across clinician groups. They consulted with electronic medical record experts to set up the reporting system.
At one hospital, 58 patients met the criteria over the study period and were screened, resulting in seven (12%) positive patients identified and put under isolation precautions. At the second hospital, 28 patients met the criteria and were screened, resulting in three (11%) identified and isolated. Overall, the two hospitals screened 86 patients, of which 10 (12%) were positive.
“Six of the 10 patients, or 60% of the positive cases, were detected after having a prior negative test result,” Paoline said.
Some had just had their last negative result as short as nine days prior and as long as 514 days.
“That range does not surprise me,” she said. “That’s one of the things that makes C. auris really tricky. A person will become colonized and their results will wax and wane. Once a patient is positive, we recommend that no further screening be conducted other than testing as part of their routine medical care. But we don’t recommend any further colonization screening, as there is no decolonization protocol for C. auris.”
The hospitals made a commitment that any patient screened as part of their protocol would be placed under contact precautions until they had a negative result back, she said.
“This is not a form of testing that they were doing on any type of routine basis,” Paoline said. “For C. auris colonization screening, the gold standard for testing is an axilla/groin composite swab. They had to train their staff on how to collect these types of swabs and also how to use the lab web portal so that they could enter their own test orders to the regional antimicrobial resistance lab.”
State health department transfer letters were used when moving any C. auris patients to another facility.3 The transfer communication warns the receiving facility that:
• The patient has been colonized or infected with Candida auris. C. auris is a difficult to detect yeast that can cause life-threatening infections and has caused long-lasting outbreaks in healthcare facilities. It is easily spread, hard to remove from the environment, and often very resistant to antifungal medications.
• Implementation of transmission-based precautions is necessary to prevent transmission, which can lead to outbreaks. Contact precautions should be implemented by acute care facilities as the primary option.
• For long-term management of these patients in nursing homes, enhanced barrier precautions should be implemented unless the resident meets criteria for more strict transmission-based precautions.
“Prior to discharge, the care coordinators were able to send a copy of the inter-facility transfer document,” Paoline said. “I think that’s really powerful — that these notifications can happen in a more automatic way, to ensure that there are no communication failures.”
REFERENCES
- Lyman M, Forsberg K, Sexton JD, et al. Worsening spread of Candida auris in the United States, 2019 to 2021. Ann Intern Med 2023;176:489-495.
- de St. Maurice A, Parti U, Anikst VE, et al. Clinical, microbiological, and genomic characteristics of clade-III Candida auris colonization and infection in southern California, 2019-2022. Infect Control Hosp Epidemiol 2022;44:1-9.
- Pennsylvania Department of Health. Healthcare facility toolkit for response to Candida auris: Materials for healthcare facilities. Updated June 2023. https://www.health.pa.gov/topics/Documents/Programs/HAIP-AS/C.%20auris%20Toolkit%20-%20Healthcare%20Facilities.pdf
The ability for emerging fungal threat Candida auris to move undetected across the healthcare continuum via asymptomatic colonized patients capable of transmitting the pathogen raises a compelling question.
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