Candida auris an Emerging Killer
Candida auris is a new fungus that has recently emerged as a super-bug (a multi-drug resistant invasive organism). Previously unknown and unidentified, this fungus was first reported in Japan, in 2009, from external ear canal cultures and thus its name “auris” from the Latin for “ear”. In 2011, the first invasive human infections were reported in South Korea and just two years later C. auris was reported in the United States. The number of cases has since grown to 799 with 60% resulting in death. The Centers for Disease Control and Prevention (CDC) track and update the number of cases monthly along with other important trends. C. auris is of a concern to global health for three main reason: it is difficult to accurately identify in the laboratory, it is resistant to available drugs, and it spreads in healthcare institutions, often, by environmental contact.
Drug Resistance
Fungal infections are treated using a variety of antifungal medications. There are three types of antifungals in existence today that can treat this Candida. These are triazoles, echinocandins and polyene and some commonly known examples of these are fluconazole, caspofungin, and amphotericin B respectively. Multi-drug resistance refers to C. auris being resistant to treatment with one or more of these classes of antifungals. The CDC reports that 90% of C. auris samples are resistant to fluconazole, 30% are resistant to amphotericin B and 5% to the echinocandins. The CDC has also reported the first pan-resistant cases, which is an alarming finding. This development means in some instances, C. auris has become resistance to all currently available drugs.
If C. auris is suspected, contact precautions and isolation practices should be followed daily and terminal cleaning with effective antifungal agents is imperative (the same agents effective against C. difficile should be used). The CDC has an excellent fact sheet that Infection Preventionist can reference. A high index of suspicion should exist if laboratory studies find Candida haemulonii or other uncommon forms of Candida. Additionally, health care facilities in New York, New Jersey, and Maryland, have reported the majority of reported cases in the US and may want to be especially vigilant. A recent New York Times article reported that in Chicago 50% of long-term ventilator dependent residents are colonized with C. auris
Risks
The emergence of C. auris as a superbug illustrates the importance of infection control and antimicrobial stewardship. The two practices are critical to preventing the further spread and global health threat of C. auris and serve to illustrate the goal of stewardship in preventing the emergence of superbugs. Skilled nursing facilities should take extra precautions in controlling the spread of C. auris as they have been identified as the original site of colonization in most reported cases. This species of fungus colonizes patients who may remain asymptomatic while spreading it to other residents and contaminating the environment (where it can remain for months). Patients most at risk for infection are those in long-term care or those that are institutionalized. Additional patient risk factors that contribute to possibility of infection are diabetes mellitus, post-surgery, chronic ventilator use, central venous catheters, and recent broad-spectrum antibiotic or antifungal use.
Preventing a Global Crisis
The rapidly developing global health crisis is illustrated, in point, by the emergence of C. auris from an unknown fungus to a pan-resistant killer in just a few short years. It is predicted that by 2050 the leading cause of death worldwide will be from drug resistant microorganisms causing an estimated 10 million deaths each year. It is our responsibility to ensure that we follow proper infection control practices and develop robust stewardship programs. The regulation issued by the Centers for Medicare and Medicaid Services (CMS) provides some guidance and enforcement of these practices. We can refer to just a few F-tags to see this. F880-882 Infection Prevention and Control, Stewardship, Infection Preventionist and F757 Freedom from unnecessary drugs. Any facilities found to be deficient in meeting requirements can be issued a “Tag” or citation and these tags carry financial and operational significance and impact on the facility. The tags are known as F-Tags because they are listed in the enforcement section of the federal regulation (this section is subpart “F” of the regulation). Treatment of infection or suspected infection in the nursing facility setting is regulated in three main areas. The first is F757 which states: “a medication regimen must be free from unnecessary drug use”. Unnecessary use is defined as “any drug used for excess duration, in an excess of dose, used with adverse consequences, or used without an adequate indication.” This last part is central and core to antimicrobial stewardship as many medications are used without a supported indication for their use. F880, 881 and 882 are regulations that require an infection control and prevention program, an antibiotic stewardship program, and lastly 882 which deals with the future requirement that a designated individual who is qualified and trained serve as an “infection preventionist” to lead the infection control and prevention programs.
Candida auris is an emerging threat in the long-term care population and demands robust infection control and stewardship programs. Preventing the rise of C. auris as a global killer depends on each of us. It is important to maintain vigilant, emphasize the proper use and disposal of protection equipment, take proper contact precautions and require robust prevention programs. The chilling fact that, if unchanged, infection will become the global killer in the next 30 years, is incredible when we consider that penicillin became widely available in 1944. It is up to each of us to ensure we do not return to an era of pre-antimicrobials and a time when minor wound infections often meant certain death.
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