The seemingly inexorable rise and spread of drug-resistant Candida auris continues in the United States, with the fungus establishing an endemic presence in some areas, accompanied by an increase in pan-resistant isolates. Concerningly, it has spread to 17 new states since 2019. The Centers for Disease Control and Prevention (CDC) reported that clinical infections increased 59% in 2020, then nearly doubled in 2021 with a 95% jump.1
Even though half of states have not had a reported case, C. auris is taking on an inevitability that suggests it might become endemic in the United States.
“I think it’s still to be determined,” says Megan Lyman, MD, the lead author of the CDC paper and a medical officer in the agency’s mycotic diseases branch. “There are definitely areas where it is much more common, but I think there’s still a lot to do to prevent spread. Even if you’re not able to eliminate it, you want to decrease the number of cases as much as possible, because each one of those patients who becomes colonized could develop an infection or spread to somebody else.”
In the CDC study, Lyman and colleagues found “ongoing transmission within and across healthcare facilities connected via patient transfers. Healthcare transmission is responsible for most, if not all, cases.”Focus on Long-Term Care
Interventions against C. auris should be prioritized in long-term care and post-acute settings, says Pat Jackson, RN, BSN, CIC, president of the Association for Professionals in Infection Control and Epidemiology (APIC)
“There really have not been major outbreaks in acute care, so I think the focus needs to be in these long-term care settings,” she says. “They haven’t been given the infection control resources that they need. This seems to be a common issue that keeps rising up — we are concerned about long-term care. During the pandemic, 40% of the COVID deaths were in long-term care.”
Although federal requirements call for a part-time infection preventionist in long-term care, these positions may be diluted by other duties, let alone all the other infections that must be dealt with, Jackson says.
“APIC continues to recommend dedicated, full-time, trained infection preventionists in long-term care,” she says.
Acute care hospitals must be vigilant about C. auris introductions, and they are the facilities best positioned on the healthcare continuum to pick up community and long-term care cases, Lyman says.
“Acute care hospitals have an important role in detecting what’s happening in their community because so many patients are being directed to them,” she says. “They see what’s going on in the community and they may detect nursing home outbreaks. If they’re seeing a lot of cases that are picked up that are coming from specific facilities, that may point to an outbreak that nobody knows is occurring."
C. auris became a nationally notifiable condition in 2019 and infections should be reported to the state or local health department and to the CDC at [email protected]. Jackson recommends getting the Centers for Medicare and Medicaid Services (CMS) involved to mandate reporting and to get the attention of the C-suite. The public health reporting probably only reflects the tip of the iceberg, she says.
The primary challenge for hospitals is identifying C. auris cases as soon as possible to get patients into isolation and prevent transmission. The fungus can be misidentified as other Candida species without high-level lab capabilities.
“If you are in a smaller community hospital like me, your automated systems might not be able to identify this or it might identify it incorrectly,” Jackson says. “If we get any species of Candida that can misidentified as C. auris, we send it out for verification."
Some hospitals have put in protocols calling for colonization screening on all patients being admitted from nursing homes, she adds. 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.3 In any case, suspected C. auris cases should be put in empiric isolation with contact precautions until the results of testing are known.
First U.S. Infection in 2013
Initially identified in Japan in 2009, the first case of C. auris occurred in the United States in 2013 and was described in a CDC report of the first seven cases in the country.4But there are good reasons why C. auris is the first fungus to be rated an “urgent threat” — the CDC’s highest-level warning for pathogenic microbes. In the threat report, with a mix of wonder and horror, the CDC recalled the moment it realized what it was dealing with: “It seemed hard to believe. CDC fungal experts had never received a report describing a Candida infection resistant to all antifungal medications, let alone Candida that spreads easily between patients.”6
Multidrug Resistance
In the CDC paper, Lyman and colleagues found that 3,270 clinical cases and 7,413 colonizations of C. auris were reported in the United States through 2019 to the end of 2021.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;Mar 21. doi:10.7326/M22-3469. [Online ahead of print].
- Mississippi State Health Department. Mississippi Candida auris Update, January 11, 2023. https://msdh.ms.gov/page/resources/19564.pdf
- 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;Sep 2:1-9. doi: 10.1017/ice.2022.204. [Online ahead of print].
- Vallabhaneni S, Kallen A, Tsay S, et al. Investigation of the first seven reported cases of Candida auris, a globally emerging invasive, multidrug-resistant fungus — United States, May 2013-August 2016. MMWR Morb Mortal Wkly Rep 2016;65:1234-1237.
- Chen J, Tian S, Han X, et al. Is the superbug fungus really so scary? A systematic review and meta-analysis of global epidemiology and mortality of Candida auris. BMC Infect Dis 2020;20:827.
- Centers for Disease Control and Prevention. Antibiotic resistance threats in the United States 2019. Revised December 2019. https://www.cdc.gov/drugresistance/pdf/threats-report/2019-ar-threats-report-508.pdf
- World Health Organization. WHO fungal priority pathogens list to guide research, development and public health action. Published Oct. 25, 2022. https://www.who.int/publications/i/item/9789240060241
- United States Environmental Protection Agency. List P: Antimicrobial products registered with EPA for claims against Candida auris. Updated Feb. 2, 2023. https://www.epa.gov/pesticide-registration/list-p-antimicrobial-products-registered-epa-claims-against-candida-auris
- Lyman M, Forsberg K, Reuben J, et al. Notes from the field: Transmission of pan-resistant and echinocandin-resistant Candida auris in health care facilities – Texas and the District of Columbia, January-April 2021. MMWR Morb Mortal Wkly Rep 2021;70:1022-1023.
The seemingly inexorable rise and spread of drug-resistant Candida auris continues in the United States. The Centers for Disease Control and Prevention reported that clinical infections increased 59% in 2020, then nearly doubled in 2021 with a 95% jump.
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