Friday, May 19, 2017

MMWR: Ongoing Transmission of Candida auris in Health Care Facilities

Credit MMWR - May 2017


Not quite 11 months ago (June 24th, 2016) the CDC issued a Clinical Alert to U.S. Healthcare facilities about the Global Emergence of Invasive Infections Caused by the Multidrug-Resistant Yeast Candida auris. 
A week later we saw a release from the UK's PHE On The Emergence Of Candida auris In The UK, where they detailed a large (and ongoing since April 2015) nosocomial outbreak at an adult critical care unit in England.
C. auris - an emerging fungal pathogen  - was first isolated in 2009  in Japan, found in the discharge from the patient's external ear (hence the name `auris'). Retrospective analysis has traced this fungal infection back over 20 years.
Unlike most systemic Candida infections, which usually arise when a previously colonized person is weakened from illness or infirmity, this strain appears to have a propensity for nosocomial transmission.
When you add in that:
  1. C. auris infections have a high fatality rate
  2. The strain appears to be resistant to multiple classes of anti-fungals 
  3. And it can be difficult for labs to differentiate between Candida strains
It's no wonder this emerging pathogen is on the CDC's radar.

Last November we looked at the MMWR: Investigation of the First Seven Reported Cases of Candida auris In the United States and just last March, in CDC Update On Candida Auris we learned the number of U.S. cases increased to more than 50.

Yesterday the CDC's MMWR carried an update, that not only describes 77 clinical cases, but also 45 `close contacts' of known cases who - while asymptomatic - were positive for C. auris isolated from one or more body sites.
The evidence is mounting that C. auris can spread easily within health care facilities and that it is a growing threat in the United States, and around the world.
Some excerpts from the MMWR report, and the latest update map from the CDC, follow.

Notes from the Field: Ongoing Transmission of Candida auris in Health Care Facilities — United States, June 2016–May 2017

Weekly / May 19, 2017 / 66(19);514–515

Sharon Tsay, MD1,2; Rory M. Welsh, PhD1; Eleanor H. Adams, MD3; Nancy A. Chow, PhD1; Lalitha Gade, MPharm1; Elizabeth L. Berkow, PhD1; Eugenie Poirot, PhD2,4; Emily Lutterloh, MD3,5; Monica Quinn, MS3; Sudha Chaturvedi, PhD3,5; Janna Kerins, VMD2,6; Stephanie R. Black, MD6; Sarah K. Kemble, MD6; Patricia M. Barrett; MSD7; Kerri Barton, MPH8; D.J. Shannon, MPH9; Kristy Bradley, DVM10; Shawn R. Lockhart, PhD1; Anastasia P. Litvintseva, PhD1; Heather Moulton-Meissner, PhD11; Alicia Shugart, MA11; Alex Kallen, MD11; Snigdha Vallabhaneni, MD1; Tom M. Chiller, MD1; Brendan R. Jackson, MD1 (View author affiliations)

In June 2016, CDC released a clinical alert about the emerging, and often multidrug-resistant, fungus Candida auris and later reported the first seven U.S. cases of infection through August 2016 (1). Six of these cases occurred before the clinical alert and were retrospectively identified.
As of May 12, 2017, a total of 77 U.S. clinical cases of C. auris had been reported to CDC from seven states: New York (53 cases), New Jersey (16), Illinois (four), Indiana (one), Maryland (one), Massachusetts (one), and Oklahoma (one) (Figure). All of these cases were identified through cultures taken as part of routine patient care (clinical cases).
Screening of close contacts of these patients, primarily of patients on the same ward in health care facilities, identified an additional 45 patients with C. auris isolated from one or more body sites (screening cases), resulting in a total of 122 patients from whom C. auris has been isolated.

Among the 77 clinical cases, median patient age was 70 years (range = 21–96 years), and 55% were male. C. auris was cultured from the following sites: blood (45 isolates), urine (11), respiratory tract (eight), bile fluid (four), wound (four), central venous catheter tip (two), bone (one), ear (one), and a jejunal biopsy (one). Antifungal susceptibility testing at CDC of the first 35 clinical isolates revealed that 30 (86%) isolates were resistant to fluconazole (minimum inhibitory concentration [MIC] >32), 15 (43%) were resistant to amphotericin B (MIC ≥2), and one (3%) was resistant to echinocandins (MIC >4).
Most (69, 90%) clinical cases were identified in the New York City metropolitan area (53 in New York and 16 in New Jersey). Nearly all patients had multiple underlying medical conditions and extensive health care facility exposure. Epidemiologic links have been found between most cases. In Illinois, three cases were associated with the same long-term care facility. In New York and New Jersey, cases were identified in multiple acute care hospitals, but further investigation found most had overlapping stays at interconnected long-term care facilities and acute care hospitals within a limited geographic area. The case in Massachusetts was linked to the Illinois cases. The cases in Indiana and Oklahoma occurred in patients who had recently received health care in other countries.

(Continue . .  )
 The CDC publishes a monthly update on cases on their Candida auris  web page.

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