Outbreak Tracker

Outbreak Tracker

September 17, 2018
3 min read

Report details ‘concerning’ emergence of C. auris in New York

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Health care facilities in New York City are experiencing a large, citywide outbreak of Candida auris at multiple health facilities, according to findings published in Emerging Infectious Diseases.

C. auris is an invasive and often multidrug-resistant fungus that can survive on hospital surfaces for extended periods of time. It has been compared to a superbug. New York has reported close to 60% of all clinical cases in the United States, according to the CDC, with most occurring in New York City.

In their report, Eleanor Adams, MD, MPH, public health physician in the New York State Department of Health, and colleagues described the detection of C. auris in New York health care facilities as “concerning.” They visited facilities with suspected transmission to “emphasize the importance of detection, assist with infection control efforts, and conduct point prevalence surveys of facility contacts.”

For the point prevalence surveys, the researchers initially collected axilla and groin composite swabs, then added swab samples from the nares in subsequent surveys. Swab samples from the axilla, groin, nares, rectum, wounds and sites of noninvasive clinical infections were collected from some people to identify persistent colonization. Adams and colleagues also looked at administrative support, hand hygiene practices and compliance, standard and transmission-based precautions and environmental cleaning to assess health care infection control.

They detected 51 clinical and 61 screening cases in New York state. (Cultures obtained for surveillance purposes were designated as screening cases, and those collected for diagnosis or treatment were clinical cases, according to the study.) Every case was diagnosed in New York City, excluding one clinical case that was detected in a western New York hospital in a patient

who had recently been admitted to a Brooklyn hospital involved in the multiple-institution outbreak, Adams and colleagues reported.

When they investigated epidemiological links between infections, the researchers said they found “a large, interconnected web of affected health care facilities” throughout the city, with 21 cases diagnosed in seven Brooklyn hospitals. In Queens, 16 cases were diagnosed between three hospitals and one private medical office. Manhattan had 12 cases in five hospitals and one long-term, acute-care hospital and one case was identified in a hospital in the Bronx.

They further found that 61% (n = 31) of the 51 clinical case-patients had resided in long-term care facilities before being admitted to the hospital where C. auris infection was diagnosed. Of them, 19 had been in skilled nursing facilities with ventilator beds, Adams and colleagues reported. Additionally, they found that 10% (n = 5) of case-patients were transferred from another hospital before being admitted to the hospital of their diagnosis, 8% (n = 4) traveled internationally within 5 years before diagnosis and 2% (n = 1) had been in a long-term acute care hospital. Subsequently, Adams and colleagues reported that because of an unknown incubation period and multiple health care exposures, it was “difficult or impossible” to determine the place of origin of the C. auris infection or colonization.

The researchers performed 1,136 screening cultures for four health care workers, four family members of one clinical case-patient and 572 people who resided in or were admitted to 19 facilities but were not known to be infected. In all, 61 people (11%) had a positive culture for C. auris at 12 facilities — five hospitals and seven long-term care facilities — and one positive culture was from a family caregiver at a private residence, they reported. Of them, 31% (n = 19) were admitted to hospitals at the time of sample collection and 67% (n = 42) resided at long-term care facilities.

Adams and colleagues conducted infection control assessments at 14 long-term care facilities and 12 hospitals and noted that adherence to recommended infection control practices varied. Reported issues included low access to alcohol-based hand sanitizers, improper donning and doffing of personal protective equipment (PPE) and an overall lack of knowledge about appropriate PPE and the use of household cleaners instead of Environmental Protection Agency-registered, hospital-grade disinfectant at some long-term care facilities.

Although the number of deaths attributable to C. auris is unknown, Adams and colleagues observed that the 30-day and 90-day mortality rate of clinical cases was 27% (n =14) and 45% (n = 23), respectively. Almost all — 98% — of isolates from clinical case-patients were resistant to fluconazole, in line with previous findings.

Adams and colleagues suggested that prolonged colonization of clinical and screening case-patients and environmental contamination may be contributing to transmission, but the reason behind the prevalence of C. auris cases in New York City is unknown.

“Possibilities include a true higher prevalence from multiple introductions into this international port of entry, more complete detection from aggressive case finding, presence of a large interconnected network of health care facilities in New York City, or a combination of all three factors,” they wrote. – by Marley Ghizzone

Disclosure: The authors report no relevant financial disclosures.