National Center for Emerging and Zoonotic Infectious Diseases

AR Lab Network Testing

Snigdha Vallabhaneni, MD, MPH CDC Mycotic Diseases Branch

July, 2018

Most Common Healthcare-Associated Bloodstream Infection in This Study? Candida 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% 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 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 drugs . 2016 IDSA guidelines recommend treating almost all forms of invasive in adults with . Echinocandins are both first line and last line of therapy against Candida infections Objectives of the Candida ARLN program . Track antifungal resistance among Candida/ 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 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.