Candida Auris and Emerging Resistant Organisms
Candida auris and Emerging Resistant Orgarnisms
Candida auris and Emerging Resistant Organisms Candida auris JOSE ANTONIO SERRANO, MPH STATUS UPDATE AND CASE IDENTIFICATION MYCOTIC DISEASE COORDINATOR – INFECTIOUS DISEASE EPIDEMIOLOGY SECTION LOUISIANA DEPARTMENT OF HEALTH – OFFICE OF PUBLIC HEALTH
Intro/Background What is C. auris?
Candida auris (C. auris) is a sub-species of the Candida genus, that can cause invasive candidiasis. Candida auris is a type of pathogenic yeast that has been reported by healthcare facilities in several countries causing severe illness in hospitalized patients C. auris was first reported in 2009 in Japan, but earliest known strain “A drug-resistant germ that spreads in healthcare facilities” dates back to S. Korea in 1996. Invasive infections could arise
F irst isolated sample being found in a patient’s ear (Auris is latin for “Ear”), C. auris affects many regions of the body Patients at higher risk of infection include: Previously received antibiotics or antifungal treatment
Spent a long time in a healthcare facility
Central line catheter, or other lines connected
Immunosuppressed
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Why is C. auris a problem? Why is C. auris a problem? (cont’d)
Aggressive spread in healthcare facilities Potential for serious infections It has been responsible for outbreaks in hospitals and nursing homes, Bloodstream infections leading to death, particularly in hospital and spreading through contact with patients and contamination nursing home patients with serious medical conditions. Good hand hygiene and cleaning is important because C. auris can Known to affect vital organs/systems (blood, heart, brain, etc.) survive on surfaces for several weeks
>30% of patients with invasive disease die It is becoming more common Difficult to identify (and easy to mis-identify) Only discovered in 2009, it has spread quickly in more than a dozen countries Can be misidentified as a number of different organisms
Unless specialized laboratory technology is used, misidentification could lead to a wrong diagnosis/treatment Anti-fungal resistance Most treatable with echinocandins Some strains found to be resistant to all three main classes of anti- fungals (polyenes, azoles, and allylamines)
Infection and colonization with C. auris Current National Situation (as of September, 2017)
As of August 31, 2017, a total of 153 US clinical cases reported to CDC: C. auris can cause invasive infection (e.g. bloodstream, intra- mainly, New Jersey and New York abdominal) All cases were identified through cultures taken as part of routine patient care (clinical cases). Screening of close contacts identified an additional 143 patients with C. However, C. auris also has been found in non-invasive body sites auris isolated from one or more body sites (screening cases), resulting in a total of 296 patients and colonization can occur
Median age: 70 years (21-96) and 55% were male Patients have been found to be colonized for several months after Nearly all had underlying conditions and extensive health care facility stays active infection has resolved. Epi-links have been found in most cases
Not enough data available to provide a max amount of time of colonization Resistance: The first 35 clinical isolates underwent susceptibility testing: Not enough data on the efficacy of decolonization with chlorhexidine 30 (86%) resistant to fluconazole or other topical agents 14 (43%) resistant to amphotericin B 1 (3%) resistant to echinocandins
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Case count and geographical Louisiana Case Definition
distribution Case classification determined by lab evidence and epi-linkage:
A case that meets the confirmatory laboratory evidence for infection:
Culture of C. auris from any body site, including blood, wound, skin, ear, urine, rectum, respiratory secretions, or other body fluids.
A case with supportive laboratory evidence and evidence of epidemiologic linkage
Detection of C. haemulonii from urine, resp. tract, or normally sterile site by a laboratory instrument not equipped to detect C. auris and isolate is not available for further testing.
Epidemiologic linkage: isolate from a person who is within the same household, same healthcare facility, or in a healthcare facility that commonly shares patients with a facility, with another person with confirmatory laboratory evidence.
Confirmed: a case that is laboratory-confirmed
Probable: a case with supportive laboratory evidence and evidence of epidemiologic linkage
Suspect: a case with supportive laboratory evidence and no evidence of epidemiologic linkage
Identification of C. auris Treatment for C. auris
Consultation with infectious disease specialist recommended Healthcare facilities or labs that suspect a patient with C. auris should contact IDEpi immediately Treatment is only recommended if clinical disease present.
CDC recommends all isolates obtained from normally sterile sites be identified to the species level so that appropriate initial treatment Based on the limited data available to date, echinocandins are the can be administered recommended initial therapy for C. auris infections Species identified from non-sterile sites should be considered Most strains in the US susceptible to echinocandins Patients undergoing treatment should be closely monitored, and follow- When treatment for suspect C. auris case failing up cultures and repeat susceptibility testing should be conducted. During suspected outbreaks or epi investigations
Switching to liposomal Amphothericin B could be considered if the All C. auris isolates should undergo susceptibility testing patient is clinically unresponsive to echinocandin treatment or has persistent fungemia for >5 days. Currently being done at the CDC AR Lab Network Lab in Tennessee
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Environmental testing and IC recommendations
Environmental testing of patients’ rooms identified C. auris from mattresses, beds, windowsills, chairs, infusion pumps, and countertops, indicating C. auris contamination. C. auris was not isolated from rooms after thorough cleaning with a sodium hypochlorite-based disinfectant.
Current infection control recommendations for C. auris-colonized or infected patients include: Other Fungal Healthcare- 1. use of Standard Precautions and Contact Precautions, 2. housing the patient in a private room, Associated Infections 3. daily and terminal cleaning of a patient’s room with a disinfectant active against Clostridium difficile spores (an update from previous disinfectant recommendations), and 4. notification of receiving health care facilities when a patient with C. auris colonization or infection is transferred.
Brief Description of a Few Yeasts/Molds Candida species Candida yeasts normally reside in the intestinal tract and can be found on mucous membranes/skin without causing infection Candida species Overgrowth of these organisms can cause symptoms to develop
Aspergillus species Most common cause of invasive fungal infections in hospitalized patients Patients at risk:
Central venous catheter, ICU, immunosuppressed, neutropenia, kidney failure/dialysis, surgery (esp. GI), diabetes, broad-spectrum antibiotics Zygomycetes species
Fourth most common cause of hospital-acquired BSI among ICU patients in the U.S.
Fusarium species Mostly Susceptible to antifungals albicans, tropicalis, parapsilosis Scedosporium species Somewhat resistant to antifungals lusitaniae, krusei, glabrata
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Aspergillus species CI of invasive Aspergillosis in Stem Cell transplant patients Most common species fumigatus, flavus, terreus, niger, versicolor
Ubiquitous, opportunistic, and environmentally-affected Prolonged exposure (via inhalation of spores)
Extremely high mortality rates associated with invasive aspergillosis >58%
Common risk factors Non-transplant population Transplant population Incidence: 0.5-3.9% Many health care centers treat without lab confirmation
Zygomycetes Fusarium species
Rare, but lethal (~80% mortality rate) Mold species known to cause a wide range of infections From superficial/locally invasive skin infections
Disease-causing species include Mucorales and Entomophthorales To disseminated BSIs, sinus/LRT infections
Mortality rate >80% at 90 days after infection onset Susceptibility: Resistant to triazoles and echinocandins Susceptible to Amp-B Susceptibility Resistant to Amp-B and triazoles
Voriconazole issue Some susceptibility to voriconazole Immune reconstitution central therapy due to neutropenia Extended-spectrum triazole approved for treatment of Aspergillosis Led to increase of incidence in hematopoietic stem cell transplant patients Reservoir (from <1% to ~4%) Environment (soil) outside of hospital settings Inverse relationship between Zygomycosis and Aspergillosis hospital-based contaminated water distribution systems
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Scedosporium species Antifungal resistance
The problems Very rare, but almost universally fatal Financial I.e. Each case of candidemia estimated to result in additional 3-13 days of Capable of adventitious sporulation (tissue involvement consistent with hospitalization and $6,000-29,000 in healthcare costs fungemia) Resistance Some types of fungal species have demonstrated increased resistance to first- and Disease manifestation: second-line antifungal meds (fluconazole and echinocandins) ~8% of C. glabrata isolates have been resistant to echinocandins Pulmonary or CNS disease in patients with severe immunosuppression ~3-6% of Aspergillus isolates have been resistant to azoles Few other remaining treatments are expensive and highly toxic Has been associated with solid organ and hematopoietic stem cell transplants Infections tend to occur later in the posttransplantation period (some studies show a median of 6 months after transplant) The causes Some fungi have natural resistance to antifungals Low doses and insufficiently long treatment courses contribute to resistance Susceptibility: Antibacterial medications contribute to antifungal resistance S. prolificans - resistant to all triazoles and echinocandins Elimination of certain bacteria in the gut create favorable conditions for fungal growth S. apiospermum – susceptible to extended-spectrum triazoles
Multi-state Fungal Endophthalmitis
On March 5, 2012, CaDPH was notified about nine clinical cases of fungal endophthalmitis from a single ambulatory surgical center
Investigation: L.A. County DPH determined that all affected patients had undergone vitrectomy with membrane peeling using a dye called Brilliant Blue-G (BBG) linked to one facility in Florida (earliest onset: November 2011) 33 confirmed and probable cases from 7 states linked to BBG and triamcinolone from the same facility Lab testing (culture and genetic sequencing) of cases resulted in: Public Health Investigations of HAI Fusarium incarnatum-equiseti isolated from BBG Bipolaris hawaiiensis isolated from triamcinolone Fungal Organisms 77% (n=23) suffered some degree of vision loss, or permanent visual impairment caused by infection MULTISTATE FUNGAL ENDOPHTHALMITIS & LOUISIANA MUCORMYCOSIS 88% (n=24) required repeat ophthalmic surgery OUTBREAKS
March 31, 2012 – company was required to recall all BBG dyes and triamcinolone solutions
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2014 Mucormycosis – Louisiana References Mikosz CA, Smith RM, Kim M, Tyson C, Lee EH, Adams E, et al. Fungal Louisiana and CDC investigated an outbreak of Mucormycosis in a pediatric hospital to determine routes of pathogen transmission endophthalmitis associated with compounded products. Emerg Infect Dis 2014; 20:248-256.
Cases were defined as a hospital-onset illness consistent with Mucormycosis, Duffy J, Harris J, Gade L, Sehulster L, Newhouse E, O'Connell H, et confirmed by culture or histopathology al. Mucormycosis Outbreak Associated with Hospital Linens. Ped Charts of affected patients were reviewed Infect Dis J. 2014; 33(5):472-6 Environmental samples were collected from air and surfaces and identified using DNA sequencing Robert A. Weinstein, Scott K. Fridkin; The Changing Face of Fungal Fungal isolates were collected from case-patients Infections in Health Care Settings, Clinical Infectious Diseases, Volume 41, Issue 10, 15 November 2005, Pages 1455– 5 case patients had Mucormycosis associated with the hospital over an 11-month period; all died. 1460, https://doi.org/10.1086/497138 All patients had conditions which made them susceptible to mucormycosis https://www.cdc.gov/ncezid/dfwed/mycotics/index.html 2 had cardiac conditions with persistent acidosis Cases occurred on different wards, and hospital linens were identified as the common contaminated exposure
Rhizopus delemar was identified and isolated from cultures of clean linens, and clean linen delivery bins from off-site laundry facility
Presenter Information
Jose Antonio Serrano, MPH Public Health Epidemiologist Mycotic Disease Coordinator Infectious Disease Epidemiology Section Office of Public Health – Louisiana Department of Health
PH: 504-568-8292 Email: [email protected]
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