Can I Get a Break From Candida auris?

CANDIDA AURIS: A NOT-SO-NEW INFECTIOUS DISEASE THREAT

There has been a lot of attention paid lately to fungal infections. In fact, it’s hard to escape media attention around all things fungus. Whether you’ve been watching the apocalyptic HBO show “The Last of Us” or reading increasing headlines about Candida auris, if you’ve got fungus on the brain, that’s likely why. The fungus among us, right? C auris isn’t a new concept, although for many first learning of it, it might feel like the latest infectious disease threat.

C auris is a relatively new infectious disease in the history of infectious diseases. Discovered in 2009, isolated from the external ear canal of a patient in Japan, this pathogen was later dated to 1996 from isolates reviewed retrospectively in South Korea.¹ It was made a nationally notifiable disease in the United States in 2018, meaning that states were required to report cases.² Why? Despite being first identified in the United States in 2013, growing case counts and a deeply worrying resistance to antifungal drugs, in addition to requiring specific laboratory methods to accurately identify it, translated to a profound concern around C auris. As a result, the disease became not only notifiable, but also a source for increased tracking and intervention efforts.

WHY ARE WE HEARING ABOUT IT NOW?

Antimicrobial resistance is one of the most concerning infectious disease threats we face, but sadly, it rarely gets the attention it deserves. The slow burn, it’s the biothreat that requires not only novel medical countermeasures, but also the integration of policy, economic, and public health interventions across health care, agriculture, travel, etc. C auris is one threat that many in infection prevention and infectious disease have known for years—patients who are infected with the yeast, especially in their bloodstream, run the risk of systemic infection that can translate to a high risk of death. The Centers for Disease Control and Prevention (CDC) lists 3 reasons for concern about the yeast, as follows:

1. It is often multidrug resistant, meaning that it is resistant to multiple antifungal drugs commonly used to treat Candida infections.
2. It is difficult to identify with standard laboratory methods and can be misidentified in labs without specific technology. Misidentification may lead to inappropriate management.
3. It has caused outbreaks in health care settings. For this reason, it is important to quickly identify C auris in a hospitalized patient so health care facilities can take special precautions to stop its spread.³

In terms of risk, this fungal infection is an equal opportunist. While those recently spending time in long-term care facilities and with lines or tubes (breathing tubes, feeding tubes, central venous catheters, etc), are at the highest risk, we’re finding that anyone can be at risk. As the CDC has noted, we’re still working to understand risk factors for C auris, but they mostly reflect those of other Candida infections, which include those with recent surgery, diabetes, and recent use of a broad-spectrum antibiotic or antifungal. Cases have been identified in a variety of patients, from infants to elderly patients, and closing the gaps in understanding what makes certain patients more vulnerable is desperately needed to get a leg up on this growing infectious disease threat. Understanding these aspects of the fungal infection is critical given that early data have revealed a case fatality rate of 30% to 60%.⁴ Invasive C auris infection puts patients at a high risk for death, and while most cases are treatable with echinocandins, some are resistant to all 3 classes of antifungal medications.

C auris isn’t one of those infectious diseases that are isolated to a small region of the world, but rather, it has been identified in 30 countries, from southern Africa to the South America and within the United States. Medical tourism can contribute to this spread as well, which makes the rapid diagnosis, isolation, and treatment of infections that much more important. Moreover, it’s not just that this fungal infection has been spreading globally since 1996, but even within the United States, we’ve seen a rapid increase in cases. Consider this: In 2019, the CDC reported 478 clinical cases and 1077 cases identified through screening. In 2020, this grew to 757 clinical cases and 1310 screening cases, and in 2021, there were 1474 clinical cases and 4040 screening cases.⁴ In 2022, the CDC reported 2377 clinical cases and 5754 screening cases. States including California, Nevada, Texas, Florida, New York, and Illinois reported the highest volume of cases, between 101 and 500. From 2020 to 2022, the number of identified clinical cases jumped by 214% and the number of screening cases increased by 339%—pretty scary when one considers that from 2013 to 2016, there were just 63 clinical cases and 14 screening cases identified across a handful of states.

Antimicrobial resistance and health care–associated infections increased during the COVID-19 pandemic, but these reported surges in cases of C auris are troubling. It’s not just that infections are deadly and can affect anyone, nor is it that proper diagnosis is challenging, or even that infections can be quite drug resistant, but when one zooms out and considers how little focus this actually appears to be getting—well, it’s frightening.

WHAT CAN WE DO?

There are several steps we can take to help halt the spread of C auris. First, education and communication are key. Sharing educational information and guidance, such as screening of high-risk patients, with health care facilities and frontline staff to ensure proper screening protocols that can help identify those at higher risk are put into place. Screening efforts can include contacts of newly identified patients with C auris infections to assess any potential for colonization. Second, ensure proper laboratory surveillance is occurring; the CDC site is really helpful for this. Third, make sure infection prevention efforts are put into place.⁵ These are some of the most important measures and include the following:

• Education during rounding is critical; share materials.

• Adherence to hand hygiene is a tried-and-true method.

• Ensure proper isolation precautions are in place for those identified patients with C auris infections (Contact Precautions or Enhanced Barrier Precautions). Closely follow CDC and/or local guidance on how to manage patients in cohort units or shared rooms to avoid transmission.

• Communicate with the patient, health care staff, and ancillary staff regarding duration of precautions. Colonization with C auris can often last for months or indefinitely, regardless of whether the infection is acute. This becomes even more important for patients transferred to other facilities; make sure to touch base with their infection prevention department.

• Cleaning and disinfection are paramount. It is critical that routine and terminal cleaning occurs with an EPA-registered disinfectant for C auris (Environmental Protection Agency List P). EPA products found on List K (those effective against Clostridioides difficile) can also be used. Make sure to closely follow the manufacturer’s directions on the use of surface disinfectants and their contact times to ensure efficacy. Thinking about those no-touch devices? The CDC notes, “Research about disinfection effective against C auris is ongoing. Data on ‘no-touch’ devices, such as germicidal UV irradiation and vaporized hydrogen peroxide, are limited, and the parameters required for effective disinfection are not yet well understood. If these methods are used, they should be used only as a supplement to standard cleaning and disinfection methods.”⁶

There are many things we can do to combat the threat of antimicrobial resistance and C auris. This is a growing and serious issue—so much so that there has been focused investment in pandemic preparedness and biodefense in President Joe Biden’s fiscal year (FY) 2023 budget, which included capacity to develop methods to halt spread through environmental exposure related to antimicrobial and antiviral surface.⁷ The proposed 2024 budget “prioritizes funding to address the ongoing risk of antimicrobial resistance. With $212 million, an additional $15 million above FY 2023 enacted, CDC will increase investments in state, territorial, and local capacity to detect and prevent emerging and existing threats through strengthened infection prevention and control, antibiotic stewardship data collection, and healthcare quality improvement efforts. This investment will provide support to help implement and achieve the goals under the National Action Plan for Combating Antibiotic-Resistant Bacteria (CARB), 2020-2025.”⁸

Although national efforts are underway, it’s critical to implement health care facility–specific efforts that center around education, screening, testing capacity, and infection prevention efforts. As the United States moves to a more sustainable approach to COVID-19, it’s important not to lose sight of other infectious disease threats we face, and especially those that are rapidly growing.

References

1. Oh M, Heyl J, Babu BA. Candida auris in the age of resistance. Cureus. 2020;12(9):e10334. doi:10.7759/cureus.10334

2.Tracking Candida auris. Centers for Disease Control and Prevention. February 14, 2023. Accessed April 20, 2023. https://www.cdc.gov/fungal/candida-auris/tracking-c-auris.html

3. General information about Candida auris. Centers for Disease Control and Prevention. November 13, 2019. Accessed April 18, 2023. https://www.cdc.gov/fungal/candida-auris/candida-auris-qanda.html

4. General information about Candida auris. Centers for Disease Control and Prevention. November 13, 2019. Accessed April 18, 2023. https://www.cdc.gov/fungal/candida-auris/candida-auris-qanda.html

5.Infection prevention and control for Candida auris. Centers for Disease Control and Prevention. January 17, 2023. Accessed April 18, 2023. https://www.cdc.gov/fungal/candida-auris/c-auris-infection-control.html

6.Infection prevention and control for Candida auris. Centers for Disease Control and Prevention. January 17, 2023. Accessed April 18, 2023. https://www.cdc.gov/fungal/candida-auris/c-auris-infection-control.html

7.The White House. Fact sheet: The Biden administration’s historic investment in pandemic preparedness and biodefense in the FY 2023 president’s budget. March 28, 2022. Accessed April 22, 2023. https://www.whitehouse.gov/briefing-room/statements-releases/2022/03/28/fact-sheet-the-biden-administrations-historic-investment-in-pandemic-preparedness-and-biodefense-in-the-fy-2023-presidents-budget/

8. HHS fiscal 2024 proposed budget. US Department of Health & Human Services. Accessed April 22, 2023. https://www.hhs.gov/sites/default/files/fy-2024-budget-in-brief.pdf