Under Cover of the Pandemic, a Deadly Fungus Spreads

While eclipsed by the COVID-19 pandemic, the multidrug-resistant fungus Candida auris continues to emerge in the healthcare settings and step-down facilities that can serve as reservoirs.

In a highly challenging situation, an infection preventionist (IP) described recently how she faced a C. auris outbreak during the height of the SARS-CoV-2 pandemic. Claudia Skinner, DNP, RN, CIC, a senior IP at Jude Medical Center in Yorba Linda, CA, detailed the situation at the 2022 annual conference of the Association for Professionals in Infection Control and Epidemiology (APIC).

During the initial outbreak of C. auris at Skinner’s facility, one patient had a bloodstream infection and survived. C. auris is fatal in about one-third of patients with an invasive infection of the blood, heart, or brain.

Another 12 patients were colonized and put in isolation, spelling a labor-intensive response from the hospital to keep the fungus in check.

“Once you have C. auris colonization, it’s going to be difficult to discharge that patient,” she said. “Many facilities are extremely hesitant to take patients who require this long-term isolation. It’s very similar to our carbapenem-resistant colonized patients. These patients will need to be maintained in contact isolation for the duration of their life. Currently, there’s no decolonization protocol. Any time they’re readmitted to a facility, they should be placed back into contact isolation.”

C. auris first was detected in Japan in 2009 and almost simultaneously began appearing in other parts of the world.

The first cases in the United States appeared in 2015 and began increasing steadily and spreading geographically. In reported clinical cases of C. auris, from March 1, 2021-Feb. 28, 2022, half the states had at least one case and California, Illinois, New York, and Florida had 101 patients or more, reports the Centers for Disease Control and Prevention (CDC).¹ C. auris was made nationally reportable in 2018, but the cases represent an undercount because the CDC relies on voluntary reports from public health departments.

The CDC categorizes C. auris as an “urgent” threat because it can be resistant to all three classes of antifungals, spreads on contact like bacteria, and takes on a spore form that requires powerful disinfectants to remove from the environment.

“It seemed hard to believe,” the CDC noted in an antibiotic-resistant threat report.² “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.”

COVID-19 and C. auris

COVID-19, both in terms of patient care demand and the general chaos of the response, contributed to the emergence of C. auris at Jude Medical, Skinner said. Many critically ill COVID-19 patients required multiple lines and were intubated and on ventilators.

The immediate challenge was blocking transmission throughout the facility, since colonized patients can shed the fungus on their skin. “Daily chlorhexidine (CHG) baths on patients really helps reduce the shedding of skin cells,” she said. “The more skin cells that are shed in a colonized patient, the greater the fungal spread. Every patient gets a daily CHG bath if they are in a high-risk unit, whether they’re colonized or not.”

The colonized patients are put in contact isolation, with a strong emphasis on hand hygiene before and after removing gloves.

“Wearing gloves is not a substitute for hand hygiene,” Skinner said. “We found that our compliance was really pretty good when a caregiver was exiting a patient care room, because they’re taking off gloves and they’re protecting themselves. Going into the room, they felt ‘If I’m putting on gloves it’s fine.’ We really had to do a lot of [education] on the need to use hand hygiene before putting on your gloves and going into the room.”

If C. auris gets on environmental surfaces or fomites, it can spread throughout a facility. Since typical disinfectants for other fungi may be ineffective, the Environmental Protection Agency (EPA) has a list of products that will kill C. auris, including hydrogen peroxide and paracetic acid.³

“During the height of the pandemic, we were always having to change to new forms of disinfectant,” Skinner said. “In fact, in one period of time, we were actually making our own bleach products. Thank goodness we’ve got a very active department that helped with the making of bleach and putting it into bottles, but there just wasn’t any further products available for purchase.”

Necessity had to be the mother of invention, since C. auris can survive for long periods on surfaces and fomites.

“Talk about environmental persistence — C. auris can live for nine-plus months in the environment,” Skinner said. “It is often seen as a colonizer in the ICUs (intensive care units), living in any tears in upholstery or cracks in any counters. There’s documentation of several ICU outbreaks because you’ve got the ideal patient population [combined] with environmental persistence.”

IPs Partner with Environmental Services

As C. auris found a foothold in the facility, Skinner and colleagues decided at one point to shut down single rooms in a high-risk unit to blast them with a hydrogen mist spray after patient discharge.

“The room had to be closed down for four hours after the [treatment], but we were able to really disinfect that unit and we definitely stopped the spread,” she said.

Ongoing disinfection focused on high-touch areas, such as bed rails, bed tables, door knobs, faucet handles, and light switches, she said.

“Anything that was close to the patient, such as the call bell button or remote,” Skinner said. “Daily cleaning of the nursing unit is also important. As nurses are going in and out of rooms, C. auris can spread out to the unit.”

Avoid unnecessary traffic in C. auris isolation rooms and be wary of anything going out the door that could serve as a fomite for transmission, she said.

“We don’t want to risk something like a stethoscope being brought out of the room [and] laid on a counter in a patient care unit,” she said. “That’s an ideal process for spread.”

As disinfection became a critical component of the C. auris response, infection prevention formed a partnership with environmental services and did transparent audits of room cleaning.

“Monitor and audit your environmental cleaning,” she said. “This is where our partnership with environmental services was really important. We let them know we were auditing — it was no secret, and there was no finger wagging.”

The IP teams used bioluminescence sponges to make marks and then go back with a black light after the room had been cleaned.

“We would take environmental services in [the rooms] and kindly show them areas that may have been missed within a room,” she said. “Again, this is a strong partnership.”

Equipment, such as bladder scanners, that is moved from room to room has to go through a cleaning process and is designated by a pink tag for reuse.

“If a wheelchair has been used, until that pink tag is put on it, it is considered dirty,” Skinner said. “And the pink tag is not to be placed on the piece of equipment until it is thoroughly cleaned and in storage.”

Patient Zero

As with any pathogen that apparently enters the facility and spreads throughout, the dogging question is, “Where did it come from?”

“Did the patient come from a skilled nursing facility (SNF), long-term acute care (LTAC), or from home?” Skinner said. “Initially, the thought was anybody coming from home was likely not to bring C. auris with them. That’s no longer the case here in Southern California, at least in our county. We have an endemic number of C. auris cases in the community. But initially, most of the cases were either from a SNF or an LTAC or they became colonized while here.”

The criteria used at the hospital is: If C. auris manifests in one to three days, it came in from the community or another facility. Anything Day 4 and after is considered hospital onset.

“The worst-case scenario for us has been that a patient is in the facility and 24 hours later this patient is identified to be a colonized C. auris,” she said. “Now we wonder, did we spread this? You don’t want to have that happen. That good, strong communication is really important.”

Common moments of communication breakdown include when a patient transfers to another facility or even to another unit in the same facility. To solve this problem, Skinner’s hospital and adjacent facilities collaborated and agreed to place a bright yellow sheet of paper on top of the incoming or transferring patient’s record to designate the presence of any infections.

“If the patient has had C. auris or Clostridioides difficile, anything that we need to be immediately aware of, we can put them into contact isolation to prevent spread,” she said. “This it’s just an easy way for them to quickly circle it by hand. It is not part of the medical record. We discard this paper once the patient is here and we’ve got all the communication in place.”

Among the many obstacles already described, C. auris is hard to identify using swabs of the axilla and groin.

“Initially, we had to send all these swabs to our state health department for testing,” Skinner said. “We later developed a process in house for testing because the state department was so overwhelmed and it often took days and days to get our results back. When you are swabbing the patient, [keep them] in preemptive contact isolation.”

Current frontline treatment for C. auris is monotherapy with an echinocandin, typically micafungin, but micafungin-resistant isolates have emerged, the CDC notes.

REFERENCES

1. Centers for Disease Control and Prevention. Tracking Candida auris. Last reviewed May 18, 2022. https://www.cdc.gov/fungal/candida-auris/tracking-c-auris.html
2. 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
3. Environmental Protection Agency. List P: Antimicrobial products registered with EPA for claims against Candida auris. Updated March 1, 2022. https://www.epa.gov/pesticide-registration/list-p-antimicrobial-products-registered-epa-claims-against-candida-auris