Issue: March 2020
Source/Disclosures
Disclosures: Chiller, Schwartz and Spec report no relevant financial disclosures. Clancy reports being awarded investigator-initiated research grants from Astellas, Merck and Cidara for projects unrelated to this topic and has served on advisory boards or consulted for Astellas, Merck, Cidara and Scynexis.
March 23, 2020
10 min read
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C. auris endures, raising questions about surveillance, reporting

Issue: March 2020
Source/Disclosures
Disclosures: Chiller, Schwartz and Spec report no relevant financial disclosures. Clancy reports being awarded investigator-initiated research grants from Astellas, Merck and Cidara for projects unrelated to this topic and has served on advisory boards or consulted for Astellas, Merck, Cidara and Scynexis.
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Candida auris, an aggressive and naturally resistant fungus with few treatment options and little support for more, has been rapidly drawing attention since the CDC issued a clinical alert about it in 2016.

More than 10 years after the fungus was first isolated in Japan, C. auris has been identified in more than 35 countries, with nearly 1,000 cases confirmed in the United States — most in Illinois, New Jersey and New York. The majority of C. auris strains are resistant to at least one class of antifungals and some are resistant to all three, including three recently reported pan-resistant cases in New York.

“We are concerned about the emergence of C. auris in recent years for a number of reasons,” Tom Chiller, MD, MPHTM, chief of the CDC’s Mycotic Diseases Branch, told Infectious Disease News. “It causes serious infection and even death, particularly in people who are already sick or in those with weakened immune systems. Its resistance to medication is unprecedented among similar types of yeast.”

Neil J. Clancy, MD
Neil J. Clancy, MD, of the University of Pittsburgh, said that facilities that do not have plans to detect and respond to C. auris “are not providing a responsible standard of care” to patients, visitors or staff.

Source: University of Pittsburgh/Aimee Obidzinski

According to CDC data, more than one-third of patients with invasive C. auris infection die.

Chiller noted that in addition to antifungal medications often not working against C. auris, the infection is difficult to identify.

“Without specialized laboratory technology, C. auris can be misidentified as other types of fungi ... which can be catastrophic for an infected person who may already have a weakened immune system,” Chiller said. “And it can spread readily in health care settings, just like bacteria. This is not the case for typical Candida, so this is something very new for these types of fungi and concerning for control.”

Infectious Disease News spoke with Chiller and other experts about C. auris testing and surveillance in facilities in the U.S.

Transparency in New York

With no official guidelines or strict recommendations in place, New York — which has seen more cases than any other state — has taken steps to become proactive about C. auris.

The state health department piloted a case management program to monitor patients colonized with C. auris after discharge, which notified health care facilities of their status. The program flagged the patients’ electronic medical records to ensure proper precautions be taken if they sought care. Through this system, researchers received data at least every 24 hours from 50 emergency departments in the city, which led to up to 18 alerts for up to 73 patients each month. Overall, researchers found that nine patients were persistently colonized with C. auris.

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New York is the first — and remains the only — state to publicize the names of medical facilities that have treated patients with C. auris. At the time the policy was announced, there were 34 hospitals and 103 nursing homes in New York affected. As of Dec. 31, there were 461 confirmed cases of C. auris in New York. Illinois ranked second in the U.S. with 288 cases, according to the CDC.

The New York Department of Health told Infectious Disease News that the decision to name hospitals was made so “people could get a sense for how widespread C. auris is in a community.” The department said the list of affected facilities should not be used by patients to decide where to seek care and that inclusion on the lists does not relate to quality of care.

“We have heard from providers that publicizing the list has reinforced the message about the regional nature of C. auris in health care facilities,” the department said.

Cornelius (Neil) J. Clancy, MD, associate professor of medicine and director of the extensively drug-resistant pathogen lab and mycology program at the University of Pittsburgh, told Infectious Disease News that there are pros and cons to publicizing the names of facilities that have treated patients with C. auris.

“[The pros are that] full transparency and dissemination of information help everyone better understand and prepare for C. auris. It is crucial to know, for example, if C. auris has been detected in a certain area and under what circumstances,” Clancy said. “[The cons are that] the danger of mandatory disclosure and publicizing affected hospitals might create or promote a culture of concealment or insufficient rigor in trying to find cases or colonized environmental niches.”

He explained that this may lead patients to avoid hospitals in which their care might be best delivered because a case of C. auris was identified there at some point.

“Now, people are specifically instructed in places like New York where reporting has been done not to use this information to make health care choices,” Clancy said. “The key is not whether a hospital has seen a case but whether they have adequate plans for identifying and treating C. auris infections and performing infection prevention.”

‘Canaries in the coal mine’

Tom Chiller, MD, MPHTM
Tom Chiller

The CDC encourages all U.S. facilities to look for C. auris, Chiller said.

“Early and accurate identification of C. auris, rigorous infection control practices and streamlined communication between facilities are critical to reducing the spread of this dangerous pathogen,” he said. “Health care facilities or laboratories that suspect they have a patient with C. auris infection should contact state or local public health authorities and CDC immediately for guidance.”

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There is no legislative mandate that requires hospitals to look for C. auris, according to Clancy.

“Many hospitals in New York do look for C. auris because there have been numerous cases in the state. Looking actively for this infection in a place like New York is appropriate and responsible,” he said. “If you are not in an area where cases have been detected, I’m not sure active surveillance is needed. That said, you need to have mechanisms in place to rapidly and accurately identify the Candida found in your hospital. You need to know that you can detect C. auris if it is present and you need to have proactive infection control plans in place in case C. auris shows up.”

Facilities that do not have plans to detect and respond to C. auris “are not providing a responsible standard of care” to their patients, visitors or staff, and some high-risk facilities should be more readily prepared than others, Clancy continued.

“It’s most important for facilities in areas that have experienced cases, or that care for large numbers of patients who may be at risk based on epidemiologic factors, such as geographic exposure,” he explained. “Certainly, experiences such as those in Orange County, California, have demonstrated the importance of nursing homes and long-term care facilities in outbreaks, and the importance of patients moving between facilities.”

In Orange County, an introduction of a single case of C. auris at a health care facility led to more than 180 colonized patients in nine facilities, according to data presented last year at IDWeek. Researchers said the outbreak was likely the result of interfacility transfers of patients before their colonization status was known. As of Oct. 3, 2019, 181 patients had been identified, including at least five who developed candidemia and 36 patients who died — although none of the deaths were directly attributable to C. auris.

At the time, researchers said the results suggested that long-term acute-care hospitals (LTACHs) and nursing facilities with ventilator units should be targeted in prevention efforts and that such high-risk facilities should consider enhanced surveillance for C. auris.

Andrej Spec, MD, MSCI
Andrej Spec

Andrej Spec, MD, MSCI, assistant professor of medicine, associate director of the Infectious Disease Clinical Research Unit and director of the invasive mycoses clinic at Washington University School of Medicine in St. Louis, said it is most important to test for C. auris at tertiary care hospitals and LTACHs.

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“They are the ones who care for the sickest, most complicated and the highest risk patients,” Spec told Infectious Disease News. “Epidemiology from across the world suggests that we will be picking up cases there if they are in the community.”

However, the decision to screen may not be entirely a question of desire. According to Spec, some facilities may not be equipped for the task.

“Many sites do not have the technology to test for it because it is missed by many of the older techniques. Infectious disease physicians would be familiar with misidentification pitfalls, but unfortunately not all hospitals have infectious disease physicians,” Spec said. “Most academic tertiary hospitals have what it takes to diagnose C. auris and are likely to be the canaries in the coal mine.”

In general, experts agreed that screening is very expensive in terms of material resources, as well as employee time and effort. Whether the expense is justified depends on what the results show.

“If there is conclusive benefit, then the costs are justified. If the benefit is not there, then the resources can be better devoted to other infection prevention measures,” Clancy said. “The threshold at which targeted screening is justified is not known, but for most U.S. hospitals and health care facilities, I do not think it is necessary or the best use of resources. Rather, for hospitals in low-risk areas, it is more important to make sure that mechanisms are in place to rapidly and accurately detect C. auris if it were to turn up during routine culturing, and that plans are in place to respond systematically to the appearance of C. auris. Most facilities would be better served by devoting full attention to hospital infections that are found everywhere, such as Clostridioides difficile, resistant bacteria, catheter infections, etc, rather than using precious resources to do surveillance screening of asymptomatic patients for C. auris.”

Clancy said targeted screening is only part of a strategy to address the threat of C. auris. Lack of preparedness is a larger concern.

“The biggest risk is having a sizeable outbreak already underway in a given area before anyone recognizes it,” he said. “Clinical infection prevention and clinical microbiology alertness to red flags is probably most important.”

Another key area of preparedness is an overall understanding of C. auris.

“The bottom line is that it’s critical we continue to identify sources and possible amplifying factors of C. auris. Improving our understanding in these areas can help us prevent future introductions of C. auris and new fungal pathogens into human populations,” Chiller said.

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In Canada, ‘little to gain’ by naming names

Ilan Schwartz, MD, PhD
Ilan Schwartz

A recent survey of hospitals in the Canadian Nosocomial Infection Surveillance Program (CNISP) revealed gaps in hospitals’ preparedness for C. auris.

Luckily, “C. auris has so far not made major inroads into Canada,” noted Ilan Schwartz, MD, PhD, assistant professor of infectious diseases at the University of Alberta.

According to Schwartz, 19 cases had been reported to the Public Health Agency of Canada at last count, although there have likely been additional cases since then. He said transmission in Canada has occurred, but only very rarely.

“What scares me about C. auris is the combination of two factors, which in isolation would be manageable but together are very problematic: antifungal resistance and the ability to persist on skin and in patient environments,” Schwartz told Infectious Disease News. “It is extremely tenacious; patients can remain colonized for a year or longer despite efforts at eradication. This leads to more opportunity for environmental contamination and spread to other patients than what we observe with other Candida species.”

Currently, Canadian facilities are not required to look for C. auris, although there is a subset of hospitals within the CNISP that have been conducting surveillance as part of a voluntary pilot program. Schwartz said there has not been centralized guidance on screening patients for C. auris, but there is a national working group set up to develop such recommendations.

According to Schwartz, although confirmed C. auris cases have been consistently referred to provincial and then national laboratories, hospitals and provincial health authorities have been reluctant to discuss these cases, possibly because of fear of stigmatization.

“In Canada, there is little to gain from identifying hospitals where patients with C. auris have been,” Schwartz said. “The risk of transmission with appropriate infection control and prevention procedures is low, and the extent of health care-associated transmission has been very limited. Publicly identifying hospitals has the potential to stigmatize them for appropriate screening and reporting procedures and could give the impression of a risk for acquisition among patients or would-be patients that is disproportionate to the reality.”

Schwartz said this could change if more health care-associated transmission occurs in Canada.

Fast Facts

Taking the initiative

According to Clancy, deciding to look for cases is an “institutional commitment,” but infectious disease, infection prevention, clinical microbiology and nursing staff need to lead the discussion.

“What you want is not that individuals are making ad hoc decisions but that there is a carefully designed and proportionate institutional plan in place. Then, if triggers are pulled, processes engage systemically,” Clancy said.

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For example, when the first patient is diagnosed, plans should already be in place for administrators, clinicians, laboratory personnel, infection prevention, housekeeping and other key players, and they should be automatically activated, Clancy said.

“Clinicians should be aware of where cases have been seen in the world, U.S. and within their own states and cities. Microbiology labs should understand their capacity to detect C. auris and have contingency plans for identification in the event of limitations locally,” he said.

In other words, facilities need to be proactive.

“Experience has shown C. auris can be very difficult to eradicate if it gets a toehold, and experience has shown it can emerge even in the most sophisticated, state-of-the-art facilities in high-income countries with advanced healthcare systems,” Clancy said. – by Caitlyn Stulpin

Disclosures: Chiller, Schwartz and Spec report no relevant financial disclosures. Clancy reports being awarded investigator-initiated research grants from Astellas, Merck and Cidara for projects unrelated to this topic and has served on advisory boards or consulted for Astellas, Merck, Cidara and Scynexis.

Click here to read the At Issue, “Should states publicize names of hospitals that have treated patients with C. auris?