A new study from Orange County, California, shows how Candida auris, an emerging pathogen, was successfully identified and contained in long-term acute care hospitals (LTACHs) and ventilator-capable skilled-nursing facilities (vSNFs).
Lead author Ellora Karmarkar, MD, MSc, formerly an epidemic intelligence service officer with the CDC and currently with the California Department of Public Health, told Medscape Medical News that the prospective surveillance of urine cultures for C auris was prompted by “seeing what was happening in New York, New Jersey, and Illinois [being] pretty alarming for a lot of the health officials in California, [who] know that LTACHs are high-risk facilities because they take care of really sick people. Some of those people are there for a very long time.”
Therefore, the study authors decided to focus their investigations there, rather than in acute care hospitals, which were believed to be at lower risk for C auris outbreaks.
The Orange County Health Department (OCHD), working with the California Department of Health and the CDC, asked labs to prospectively identify all Candida isolates in urines from LTACHs between September 2018 and February 2019. Normally, labs do not speciate Candida from nonsterile body sites.
Dan Diekema, MD, an epidemiologist and clinical microbiologist at the University of Iowa, Iowa City, who was not involved in the study, told Medscape, “Acute care hospitals really ought to be moving toward doing species identification of Candida from nonsterile sites if they really want to have a better chance of detecting this early.”
The OCHD also screened LTACH and vSNF patients with composite cultures from the axilla-groin or nasal swabs. Screening was undertaken because 5%–10% of colonized patients later develop invasive infections, and 30%–60% die.
The first bloodstream infection was detected in May 2019. Per the report, published online September 7 in Annals of Internal Medicine, “As of 1 January 2020, of 182 patients, 22 (12%) died within 30 days of C auris identification; 47 (26%) died within 90 days. One of 47 deaths was attributed to C auris.” Whole-genome sequencing showed that the isolates were all closely related in clade III.
Experts conducted extensive education in infection control at the LTACHs, and communication among the LTACHs and between the long-term facilities and acute care hospitals was improved. As a result, receiving facilities accepting transfers began culturing their newly admitted patients and quickly identified 4 of 99 patients with C auris who had no known history of colonization. By October 2019, the outbreak was contained in two facilities, down from the nine where C auris was initially found.
Diekema noted, “The challenge, of course, for a new emerging MDRO [multi-drug resistant organism] like Candida auris, is that the initial approach, in general, has to be almost passive, when you have not seen the organism…Passive surveillance means that you just carefully monitor your clinical cultures, and the first time you detect the MDRO of concern, then you begin doing the point prevalence surveys…This [prospective] kind of approach is really good for how we should move forward with both initial detection and containment of MDRO spread.”
Many outbreak studies are confined to a particular institution. Authors of an accompanying accompanying editorial commented that this study “underlines the importance of proactive protocols for outbreak investigations and containment measures across the entirety of the health care network serving at-risk patients.”
In her research, Karmarkar observed that “some of these facilities don’t have the same infrastructure and infection prevention and control that an acute care hospital might.”
She told Medscape, “One of the challenges was that people were so focused on COVID that they forgot about the MDROs…Some of the things that we recommend to help control Candida auris are also excellent practices for every other organism including COVID care…What I appreciated about this investigation is that every facility that we went to was so open to learning, so happy to have us there. They’re very interested in learning about Candida auris and understanding what they could do to control it.”
While recent attention has been on the frightening levels of multidrug resistance in C auris, Karmarkar concluded that the “central message in our investigation is that with the right effort, the right approach, and the right team this is an intervenable issue. It’s not inevitable if the attention is focused on it to pick it up early and then try to contain it.”
Karmarkar reports no relevant financial relationships. Diekema reports research funding from bioMerieux, Inc and consulting fees from Opgen, Inc.
Ann Intern Med. Published online September 7, 2021. Abstract, Editorial
Judy Stone, MD, is an infectious disease specialist and author of Resilience: One Family’s Story of Hope and Triumph Over Evil and of Conducting Clinical Research , the essential guide to the topic. You can find her at drjudystone.com or on Twitter @drjudystone.
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