Candida auris Outbreak Continues in New York

A large outbreak of infections caused by the yeast Candida auris remains ongoing in health care facilities in New York City and poses a concerning public health threat.

Eleanor Adams, MD, MPH, from the New York State Department of Health, New Rochelle, New York, and colleagues describe the outbreak in the October 2018 issue of Morbidity and Mortality Weekly Report from the US Centers for Disease Control and Prevention (CDC).

This novel, emerging pathogen has caused severe illness in hospitalized patients around the world and is often multidrug-resistant. Cases of infection have also been identified in the United States.

“As of February 2018, most confirmed clinical cases in the United States had been identified in New York, and case numbers continue to grow,” the authors write. “The reasons for the preponderance of cases in New York are unknown.”

From 2013 to 2017, the yeast was found to be responsible for an ongoing outbreak of health care-associated infections in several health care facilities in New York City.

The researchers investigated the outbreak by using a combination of laboratory active surveillance methods, record reviews, site visits, contact tracing with culturing, and environmental culturing.

Overall, they identified 51 clinical cases and 61 screening cases at interconnected health care facilities throughout the city.

All of the clinical case-patients had serious concomitant medical conditions, and 23 (45%) of them died within 90 days of diagnosis, according to the authors; fifty (98%) of C auris isolates from these patients were resistant to fluconazole.

Among 572 screening case-patients, 61 (11%) tested positive for the yeast on fungal culture. Additionally, samples cultured from 15 of 20 health care facilities also tested positive for C auris.

The investigators also found that some C auris infections had initially been misdiagnosed. From July 2016 through April 30, 2017, the New York State Department of Health (NYSDOH) had received 99 first isolates of different years from 99 patients for C auris testing. The Department initially identified 38 as C haemulonii. However, 35 of those 38 isolates were ultimately found to be C auris. Additionally, “[O]f 13 yeasts received with no identification, 11 were determined to be C auris, and of 6 received with a preliminary identification of C auris, 5 were confirmed as such,” Dr. Adams and colleagues write.

Individuals who had been in contact with C auris-infected patients were also frequently colonized by the yeast but had no symptoms of the disease, they note.

Environmental surfaces—including windows, floors, and beds—in the hospital rooms of clinical case-patients also commonly tested positive for C auris.

Infection prevention and control lapses were also commonly identified at the health care facilities, especially with respect to use of personal protective equipment, alcohol-based hand sanitizers, and environmental disinfectants. The presence of signs with instructions about infection control precautions was also often lacking.

These lapses prompted the NYSDOH to conduct substantial infection prevention and control efforts, according to the authors. “[T]he goals are delaying endemicity, preventing outbreaks within facilities, reducing transmission and geographic spread, and blunting the effect of C auris in New York and the rest of the United States.”

Dr. Adams and colleagues conclude that clinicians should consider C auris as a causative agent in any medically fragile patient in New York City who has symptoms of a bloodstream infection and a history of extensive contact with health care facilities.

Dr. Parry graduated from the University of Liverpool, England in 1997 and is a board-certified veterinary pathologist. After 13 years working in academia, she founded Midwest Veterinary Pathology, LLC where she now works as a private consultant. She is passionate about veterinary education and serves on the Indiana Veterinary Medical Association’s Continuing Education Committee. She regularly writes continuing education articles for veterinary organizations and journals and has also served on the American College of Veterinary Pathologists’ Examination Committee and Education Committee.