Rapid Assessment, Infection Control Measures Key to Containing Spread of Candida Auris

Enhanced laboratory surveillance and infection prevention and control practices were effective at identifying and containing Candida auris infections in southern California, a new study found.

The study, published in the Annals of Internal Medicine and funded by the Centers for Disease Control and Prevention, assessed the prevalence of C auris and infection control practices at 14 ventilator-capable skilled-nursing facilities (vSNFs) and three long-term acute care hospitals (LTACHs) in southern California.

“Our investigation is an example of how strong public health action, combined with better infection control in long-term care, can make a difference in the fight against C. auris,” lead author Ellora Karmarkar, MD, MSc, of the California Department of Public Health told Contagion.

The multidrug resistant yeast, which persists for weeks on patients’ skin and environmental surfaces, has become more prevalent in recent years. C. auris was identified in Orange County in February 2019, after urine screening was implemented, prompting the investigation.

“When Candida auris was identified, we were concerned that it was potentially in many other facilities and had not been identified yet,” Karmarkar said. “We proactively tested patients in multiple long-term care facilities and identified previously undetected cases, allowing for implementation of appropriate infection prevention and control to prevent spread and careful follow-up. These efforts helped contain C auris in the region within several months.”

Point prevalence surveys (PPSs), postdischarge testing and assessments of infection prevention and control (IPC) practices were conducted in 17 facilities. PPSs were repeated every two weeks in facilities where C auris was detected and IPC support was provided.

The investigation identified 44 additional patients with C auris in nine facilities, and the first bloodstream infection was reported in May 2019. By October 2019, a total of 182 cases were identified, including 81 isolates that were highly related. The investigation identified gaps in hand hygiene, transmission-based precautions and environmental cleaning, and the outbreak was contained to two facilities by October 2019.

Karmarkar said there were two surprising findings: “One: Over half, or 9 of 17 facilities we investigated, had C auris cases; many which we would not have identified if we did not go looking for C auris. Two: Under the right circumstances and with proactive, intensive effort that combines surveillance and infection prevention and control, we can contain the spread of C auris. It is not easy, but it can be done.”

Long-term care facilities are common places for C auris to spread. Frequent transfers between facilities promote spread of the pathogen. Proactive surveillance was key to identifying the presence of C. auris months before the emergence of bloodstream infection.

“I think this investigation reflects on our health system overall, not just LTACHs and vSNFs or other post-acute care facilities,” Karmarkar said. “Most clinicians already know that pathogens present in one healthcare facility can easily spread to others through patient transfers, so it’s important to keep those facility transfers in mind when considering precautions for multidrug-resistant organisms and when considering screening protocols.”

The study also underscored the importance of adhering to infection prevention and control practices including hand hygiene.

“So bottom line: If you detect C auris in a patient, think hard about where they might have been exposed,” Karmarkar said. “If you see one case, there are likely many others undetected. And don’t think just about your hospital or long-term care facility, but think about the local network of facilities. Report the case as soon as possible to public health, and consider collaborating with your local public health department earlier to determine the best strategies for C auris detection and containment, including stronger infection prevention and control practices.”

C auris has drawn increasing interest as cases have become more common in recent years. Jeffrey Rybak, PharmD, PhD, instructor, Department of Pharmaceutical Sciences, St. Jude Children’s Research Hospital, recently spoke about the challenges C. auris presents, including that it is often resistant to drugs, it is newer and therefore difficult for labs to diagnose and it can quickly spread in healthcare settings.

Infection preventionists at UCLA recently launched an initiative to establish strategies and protocols for addressing the pathogen, including risk assessment in admissions screening, reminders for cleaning protocols, and education of clinicians.