In 2018, Candida auris (C. auris) was made a nationally notifiable condition. In West Virginia, C. auris is a Category II emerging infectious disease and is reportable to the county health department within 24 hours.
The Wheeling-Ohio County Health Department has been following several reported cases of C. auris in Ohio County. More recently C. auris has been identified in waste water testing through the City of Wheeling’s waste water treatment plant.
The West Virginia Department of Health and Human Resources (DHHR), Bureau for Public Health (BPH) is investigating the first confirmed case of C. auris emerging from West Virginia. Controlling the spread of multi-drug resistant organisms is a public health priority. This Health Advisory is intended to provide recommendations regarding laboratory identification, treatment options, and infection control to mitigate C. auris transmission. Healthcare providers should maintain vigilance for clinical illness that could be consistent with C. auris and maintain awareness to contain the spread.
Background
C. auris is an emerging fungus that can colonize the skin and cause invasive infections. It has been associated with 30% – 72% crude in-hospital mortality. In 2022, there were 2,377 clinical cases and 5,754 screening cases across 29 states. C. auris can spread rapidly within healthcare facilities, especially in high-acuity long-term care settings, colonizing large proportion of patients. The Centers for Disease Control and Prevention (CDC) and BPH are concerned about C. auris for three reasons:
- This yeast often does not respond to commonly used antifungal drugs, making infections difficult to treat.
- It is difficult to identify with standard laboratory methods, and it can be misidentified in labs without specific technology which could lead to inappropriate management.
- It has caused healthcare setting outbreaks in the U.S. Outbreaks of C. auris have proven very difficult to control, requiring intensive public health and facility-level intervention. For this reason, it is important to quickly identify C. auris in a hospitalized patient so healthcare facilities can take special precautions to stop its spread.
Risk Factors
Persons who have recently spent time in hospitals and nursing homes and have invasive devices (e.g., mechanical ventilation or tracheostomy, feeding tubes and central venous catheters) appear to be at highest risk for infection. Other risk factors include recent surgery, diabetes, broad-spectrum antibiotic and antifungal use. Infections have been found in patients of all ages.
Transmission
C. auris can spread in healthcare settings through contact with contaminated environmental surfaces or equipment from person to person. C. auris can persist on surfaces in healthcare environments such as high-touch surfaces including bedside tables and bed rails. C. auris has also been identified on mobile and reusable equipment shared between patients such as glucometers, temperature probes, blood pressure cuffs, nursing carts, etc. Transmission is not thought to occur via persistent colonization of healthcare workers.
Diagnosis
Some phenotypic methods for yeast identification can misidentify C. auris as a number of different organisms. The use of Matrix-Assisted Laser Desorption/Ionization Time of Flight (MALDI-TOF) is the most reliable way to detect C. auris. Molecular methods based on DNA sequencing can also identify C. auris. For more information regarding testing visit: www.cdc.gov/fungal/candida-auris/health-professionals.html.
Treatment
CDC does not recommend treatment of C. auris identified from non-invasive sites (such as respiratory tract, urine, and skin colonization) and treatment is generally only indicated if clinical disease is present. To date, an echinocandin drug is the recommended initial therapy for treatment of C. auris infections. For detailed information on dosing, see the CDC recommendations for treatment of C. auris infections: https://www.cdc.gov/fungal/candida-auris/c-auris-treatment.html#treatment.
Infection control measures should be used for all patients with C. auris, whether infected or colonized, and regardless of the source of specimen. Transmission-based precautions should not be discontinued when treatment for an infection ends but should be continued for the duration of the patient’s stay in a healthcare facility and implemented for any future healthcare stays.
Infection Control
- Report any suspect or confirmed C. auris test results to the county health department within 24 hours. A single case of C. auris (infection or colonization) requires a robust public health investigation.
- Place patients who are infected or colonized with C. auris on Contact Precautions and whenever possible, in a single room. For nursing home residents, Enhanced Barrier Precautions should be used.
- Work with BPH/county health department staff to screen individuals who have had contact with a patient with C. auris infection or colonization. Testing for C. auris colonization is available through the Antimicrobial Resistance Laboratory Network. This testing is free of charge in coordination with BPH. For detailed information about screening, see the CDC recommendations for C. auris colonization: https://www.cdc.gov/fungal/candida-auris/c-auris-screening.html.
- Reinforce hand hygiene practices. Increase audits for hand hygiene, personal protective equipment (PPE) and environmental cleaning on units where patients with C. auris are located. Consider re-educating healthcare personnel through an in-service or retraining, especially if audits demonstrate low adherence, on infection prevention and control practices.
- Ensure the patient care environment is cleaned using a disinfectant with an U.S. Environmental Protection Agency (EPA) claim for C. auris (see EPA’s list P). If not available, for Clostridioides difficile (see EPA’s list K).
- When a patient is transferred (e.g., to a nursing home or other hospital), clearly communicate the patient’s history of C. auris to receiving healthcare providers.