Candida Auris is a relatively new fungus that was unknown and unidentified before 2009. It was first detected in Japan, and it has since been cultured in nearly 30 countries. In 2013, it reached the United States, and since then, New York City, Chicago, and New Jersey have seen the most cases.
The fungus is insidious, appears to infect those most vulnerable, and is nearly impossible to eradicate. The New York Times reports that in 2015, an infectious disease expert from the Imperial College of London received a call from the Royal Brompton Hospital. Dr. Johanna Rhodes was the Infectious Disease expert in question, and she was told the fungus had begun growing three months earlier, and couldn’t be cleared out.
Rhodes directed the hospital to use a device that aerosolized hydrogen peroxide, under the theory the vapor could reach where the cleaning crew could not. The device was left in place for a week, after which the room was cultured. The only organism that grew was Candida Auris.
The Centers for Disease Control and Prevention (CDC) track and update the number of cases each month. As of June 2020, there were 1,208 confirmed cases. The majority of these occurred in Illinois, New York, New Jersey, California, and Florida. The CDC calls C. Auris an “emerging fungus that presents a serious global health threat.”
Candida Auris: A Highly Contagious, Multidrug-Resistant Killer
According to the CDC, there are five reasons the fungus has become such a concern to the global health community:
- Fatal Infections
The fungus causes serious infections – more than 30% of people die within the first 30 days of diagnosis.
- Multi-Drug Resistance
It is often resistant to multiple drugs.
- Becoming Common
The infection is becoming more common.
- Difficult to Identify
Candida Auris infections are difficult to identify but critical to start treatment early to prevent spread and outbreaks.
- Highly Contagious
The infection can spread easily within healthcare facilities and colonize patients for months.
Currently, the CDC has identified two medications used for the treatment and management of Candida Auris infections. The first class of antifungals, echinocandin, can be used in infants older than two months up through adulthood. Neonates and infants younger than two months are first given amphotericin B deoxycholate. If the child is unresponsive, the next option is liposomal amphotericin B. In exceptional circumstances, echinocandins may also be used with caution.
What is antibiotic resistance?
Antibiotic resistance is a term used to describe what happens when bacteria and fungi have developed a resistance to the drugs designed to kill them. Infections caused by antibiotic-resistant pathogens, sometimes called superbugs, are difficult to treat – sometimes even impossible. Health experts have warned for decades the overuse of antibiotics would lead to a reduction in antibiotic effectiveness, ushering in a potential explosion of deaths from bacteria and fungi that were once easily treated.
Currently, the numbers suggest up to 50,000 people die each year from antibiotic-resistant pathogens in Europe and the U.S. Globally, that number is close to 700,000 dying from the drug-resistant illness. However, a more recent estimate using 2010 data suggests the number of people dying from multi-resistant bacteria in the U.S. is closer to 162,000. Some experts even predict that number will rise to 10 million people worldwide by 2050. This estimate is greater than the 8 million deaths expected from cancer within that same year.
Proper Infection Control Practices Required to Stem the Tide
With each year the risk of a Candida Auris explosion grows, and with it, the need for proper infection control practices continues to grow too. When the CDC identified three chronically ill individuals in New York with a pan-resistant C. Auris infection, it became clear that the fungus had developed a resistance to currently available drugs. The CDC recommends several early detection and infection control procedures to limit the spread of the fungus, in patients and within facilities.
Contact precautions and isolation procedures should be followed daily, as well as cleaning with an effective antifungal agent. While Candida Auris is difficult to culture, laboratory cultures of candida haemulonii or other uncommon, related forms should lead to a high level of suspicion.
The emergence of this fungus as a superbug illustrates the need for general and ongoing infection control practices, as well as a high level of antimicrobial stewardship. Both are necessary to reduce the spread of the infection as well as help control the emergence of more antibiotic-resistant pathogens. Precautions should be taken at nursing facilities to control the spread of this and other fungal and bacterial infections, as they may be the original site of colonization.
Particularly dangerous is the fact that patients can be asymptomatic as they spread the fungus to other residents, unknowingly contaminating the surrounding environment. People who are in long-term care are the most vulnerable to a Candida Auris infection. Additionally, chronic diseases and other factors that impact an individual’s immune system place them at greater risk, such as Type 2 diabetes, chronic ventilator use, central venous catheters, and recent broad-spectrum antibiotic or antifungal use.
Antimicrobial Stewardship: Regulatory Practices Offer Guidance
It is the responsibility of every person, in and out of healthcare, to follow proper infection control practices for bacterial and fungal infections to reduce the need for antibiotics and antifungal drugs, thus, hopefully slowing the development of drug-resistant pathogens. Developing robust stewardship programs requires education, and knowledge should be spread throughout the local, regional, and national communities.
The Centers for Medicare and Medicaid Services (CMS) provides some guidance and enforcement for practices in skilled nursing facilities and other residential care locations. In the enforcement section of the federal regulation, there are regulations known as F-tags. F-tags refer to subpart F of the regulation. The CMS regulates three main areas in the treatment of a confirmed or suspected Candida Auris infection in a nursing facility.
The first is F757 which states: “a medication regimen must be free from unnecessary drug use,” which is defined as “any drug used for an excess duration, in an excess of dose, used with adverse consequences, or used without an adequate indication.”
This last statement is foundational to reducing the risk of antibiotic resistance, since antibiotics or antifungals often may be used without a supported indication for their use. The CDC reports these medications are prescribed unnecessarily up to 75% of the time. Additional regulations include F880, 881, and 882, which address infection control and prevention programs, antibiotic stewardship programs, and the requirement for professionals serving as “infection preventionists” who lead infection control and prevention programs.
Candida Auris: Curbing the Emerging Threat
Candida Auris is an emerging threat in the long-term care population, and, as has been demonstrated, infectious disease pathogens continue to emerge, driving home the absolute necessity to protect vulnerable populations and better steward antimicrobial medications. In doing so, we raise the potential they remain effective as new treatments are discovered.
Preventing the rise of C. Auris depends on each healthcare professional to maintain vigilance in the use and disposal of protection equipment, education of patients and families, and the development of robust prevention programs. If left unchanged, infections will become the global killers they were before 1944 when penicillin became widely available, and society will again enter an era of pre-antimicrobials when minor wound infections often meant certain death.
The views and opinions expressed in this blog post are those of the authors and do not necessarily reflect the official policy or position of The Eastern Herald.