National Center for Emerging and Zoonotic Infectious Diseases
AR Lab Network Candida Testing
Snigdha Vallabhaneni, MD, MPH CDC Mycotic Diseases Branch
July, 2018
Most Common Healthcare-Associated Bloodstream Infection in This Study? Candida species 18000 16000 14000 12000 10000 8000 6000
CLABSI (No.) 4000 2000 0 Bloodstream infections with Candida are associated with 30% mortality Candida species distribution from the Emerging Infections Program, 2008-2017 (n=~8000 bloodstream isolates)
C. albicans, C. tropicalis, 39% 9% C. parapsilosis, 16%
C. glabrata, 28% Fluconazole Resistance (all species) by EIP Surveillance Site 2008-2017 (n=7783 isolates)
16.0%
14.3% 14.0%
12.0%
CA 10.0% CO 9.5% GA 8.0% MD MN % Resistant % 6.0% NM 5.7% NY 4.7% 4.0% 4.1% OR TN 2.3% 2.0% 1.8% OR,CA: 0.0 0.0% 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Year Echinocandin Resistance (all species) by EIP Surveillance Site 2008-2017 (n=7783 isolates)
15.0%
13.0%
11.0% CA
9.0% CO GA MD 7.0% MN
% Resistant % NM 5.0% NY OR 3.0% TN 1.9% 1.8% 1.7%1.4% 1.0% CA, NM, NY, OR, TN: 0.0 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 -1.0% Year Echinocandin-resistant C. glabrata by Surveillance Site 2008-2017 (n=2230 isolates)
15.0%
13.0%
11.0% CA
CO 9.0% GA
7.0% 6.5% MD 6.3%
% Resistant % 5.9% MN 5.0% NM 3.6% 3.0% NY
OR 1.0% TN
-1.0% 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017CA, NM, NY, OR, TN: 0.0% Year Important to monitor for resistance through ARLN . Many clinical labs don’t perform species identification for Candida, let alone resistance testing . Only three main classes of antifungal drugs . 2016 IDSA guidelines recommend treating almost all forms of invasive Candidiasis in adults with echinocandins . Echinocandins are both first line and last line of therapy against Candida infections Objectives of the Candida ARLN program . Track antifungal resistance among Candida/yeast species . Identify emerging resistant species like Candida auris and respond to outbreaks Candida auris: Why you should really care Why is Candida auris a public health threat? . Highly drug-resistant yeast . Causes invasive infections associated with high mortality . Spreads easily in healthcare settings . Difficult to identify
All the makings of a fungal superbug! Major Antifungal Resistance Seen 1 2 3
>90% 7% 35% Azoles Echinocandins Polyenes . >40% multidrug resistant . A few resistant to all three classes Causes invasive infections . 50% of clinical cases are bloodstream infections
. 40% in-hospital mortality in BSI cases Affects the sickest of the sick . Older age . Multiple healthcare stays (acute and long term) . PEG . Central catheters . Tracheostomy . Ventilator . On antibiotics and antifungals Candida auris is difficult to identify X X X
* Ver 8.01 software
* RUO with Saramis Ver 4.14 Challenges with identification
. >40% of clinical cases in the US have been from non- bloodstream isolates (e.g.,
urine, bile, wounds) Initial culture site of C. auris clinical cases (n = 150)
. Species from non-sterile isolates often not identified LTCF Point prevalence Survey for C. auris colonization
C. auris colonization prevalence = 43% (29/67)
C. auris positive Screened negative for C. auris Not tested for C. auris (refused or not in room) Slide courtesy of Janna Kerins, S. Black / W. Clegg (CDPH) Confidential. Do not cite or distribute. C. auris persists in the environment Healthcare abroad is risk factor for C. auris . 11 U.S. cases have links to healthcare abroad . US C. auris cases are a result of introductions from abroad followed by local transmission C. auris Colonization Testing Why is screening for colonization important? . Colonized people are at risk of spreading C. auris to others . Colonization is a risk factor for invasive infection – ~30 cases of colonized patients developing an infection – Can implement interventions like catheter care if known to be colonized . Detect otherwise hard to spot transmission – C. auris very difficult to get rid of once it takes hold in facilities Sites of C. auris Colonization
. Most sensitive (>90%) and cost-effective swab: axilla and groin
. Patients remain persistently colonized When to screen . Contact tracing around a newly identified case . Point prevalence surveys in places with some documented transmission . Admission screening . Screening of patients with history of healthcare abroad . Screening of patients in long-term care facilities, especially those with CP- CRE and other MDROs General colonization testing process . Colonization testing is needed . Facility or public health conducts swabbing . Swabs and data sent directly to ARLN or to ARLN through SPHL . ARLN tests swabs . ARLN reports results within 1 working day . Monthly ARLN reports submitted to CDC C. auris nationally notifiable . Currently reportable in 8 states . Encourage other states to make it reportable . Operational guidance in progress Action steps What to submit for AR Lab Network Other ideas for getting in front of C. auris . Consider doing a lab survey to figure out clinical lab’s capacity to detect C. auris . Consider sending out a clinical alert . Consider making it reportable . Be prepared: Decide protocol for suspected isolates and for swabs – Send straight to ARLN lab or go through state?
Early identification is key! Thank you! Questions?
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The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.