CDC Warns of Link Between Overseas Hospitalization, CPOs, and C auris

A new report from the US Centers for Disease Control and Prevention (CDC) warns health care organizations and providers that overseas hospitalization and carbapenemase-producing organism (CPO) colonization or infection should be seen as warning signs for the presence of Candida auris.

The warning, published in the CDC’s Morbidity and Mortality Weekly Report, comes after a case in Maryland last September in which a patient was admitted to the hospital with multiple CPO colonizations/infections. The patient had previously spent a month in a Kenyan hospital after suffering a cerebral hemorrhage while visiting the African country. The patient’s treatment in Kenya involved several operations and complications, as well as the insertion of a feeding tube. After being medically evacuated to the United States, hospital staff decided to test the patient for C auris, an emerging drug-resistant yeast that has been found in patients in approximately 30 countries since it was first identified in Japan in 2009. C auris is particularly problematic because many of the symptoms are similar to those of other medical conditions. The infection can be deadly, especially if an accurate diagnosis is delayed.

The Maryland patient was found to have C auris colonization, but not infection. The hospital then evaluated 21 patients who had been in the same unit, but none of those patients tested positive for C auris colonization or infection.

The CDC recommends that anyone who has been hospitalized overnight overseas in the past 12 months be screened for C auris. The agency also recommends contact precautions and CPO screening for any patient with an overnight overseas hospital stay in the previous 6 months.

Richard B. Brooks, MD, of the Division of Healthcare Quality Promotion at the CDC’s National Center for Emerging and Zoonotic Infectious Diseases, told Contagion® that overseas travel is an important risk factor for C auris, but he said awareness of the link between C auris and receiving care overseas varies from hospital to hospital and provider to provider.

In the case of the Maryland patient, public health officials were already on alert since the health department had previously found CPOs and C auris in a patient who had been hospitalized in India.

Unfortunately, Brooks said, many hospitals miss opportunities for screening because they are unaware that a patient has traveled overseas.

“It’s important to get an accurate and complete travel history when admitting a patient to the hospital, but it’s not always done,” he said. “During the Ebola outbreak in West Africa in 2015 and the Zika outbreak in 2016, providers became much more focused on getting this information. But, as those outbreaks resolved, the attention paid to collecting this information also waned.”

In their report, Brooks and colleagues urge providers and hospitals to be on the lookout for C auris for patients hospitalized overseas even if the country to which the patient traveled is not known to have had problems with C auris.

“Because C auris can be difficult to identify by some routinely used lab tests, the fact that C auris has not been reported from a country does not necessarily mean it’s not there,” he said.

As of August 2, 2019, the CDC had tallied 11 cases of patients in the US who had been diagnosed with C auris infection or colonization after receiving medical care overseas. Of those, 6 were also known to have been colonized with CPOs, though Brooks and colleagues noted the actual rate of CPO co-colonization could be higher, since not all patients were assessed for CPO colonization.

If a patient is indicated for C auris screening, Brooks cautioned that most routine hospital testing platforms can easily misidentify C auris, and he noted that commercial testing is not currently available to hospitals. However, Brooks said the CDC’s Antibiotic Resistance Laboratory Network will perform the test free of charge. Health care facilities can request testing through their state health departments. The test itself is simple, he said.

“Screening for C auris colonization requires gently rubbing a cotton swab over a patient’s skin in their axillae (armpits) and groin areas, and is not particularly difficult, invasive, or time-consuming,” he said.