Articles, Blog

CDC COCA Call: Multidrug-resistant Candida auris

August 13, 2019


>>Good afternoon. I’m Kondra Williams, and I’m
representing the Clinician Outreach and Communication
Activity, COCA, with the Emergency Risk
Communication Branch at the Centers for Disease
Control and Prevention. I’d like to welcome you
to today’s COCA Call, Multidrug resistant
Candida auris: Update on Current U.S.
Epidemiology, Clinical Profile, Management, and Control
Strategies. You may participate in today’s
presentation via webinar, or you may download the
slides if you are unable to access the webinar. The PowerPoint slides and
the webinar link can be found on our COCA web page at
emergency.cdc.gov/coca. Again, the web address is
emergency.cdc.gov/coca. Free continuing education
is offered for this webinar. Instructions on how to earn
continuing education will be provided at the end of the call. In compliance with continuing
education requirements, CDC, our planners, our presenters,
and their spouses’ partners wish to disclose they have
no financial interest or other relationships
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to ensure there is no bias. Content will not include any
discussion of the unlabeled use of a product or a product
under investigational use. CDC did not accept
commercial support for this continuing
education activity. There will be a Q&A session after the speakers
have presented. Please note that you may
submit questions at any time through the webinar system
by clicking the Q&A button at the bottom of your screen,
and then type in your question. Please do not ask a question
using the chat button. Questions regarding the webinar
should be entered using the Q&A button. For those who have
media questions, please contact CDC Media
Relations at 404 639 3286, or send an e mail
to [email protected] If you are a patient,
please refer your questions to your healthcare provider. At the conclusion
of this session, participants will be able
to accomplish the following. Describe risk factors
for C. Auris infection and colonization, discuss
resistance patterns in C. Auris, describe evolving treatment
options for C. Auris, define steps to take when a case of C. Auris is suspected
or identified. Today’s first presenter
is Dr. Tom Chiller. Dr. Chiller is an
infectious disease physician who has specialized in fungal
diseases for the past 20 years. He leads CDC’s efforts
to combat fungal diseases as the Branch Chief of the
Mycotic Diseases Branch in the Office of Emerging
Infectious Diseases and the National
Center for Emerging and Zoonotic Infectious
Diseases. He attended Tulane School of
Medicine and the Tulane School of Public Health and
Tropical Medicine. Our second presenter is
Dr. Snigdha Vallabhaneni. Dr. Vallabhaneni is an
infectious disease physician and medical epidemiologist
at CDC. She has led CDC’s response
to the emergence of C. Auris, including describing the initial
C. Auris cases in the U.S., supervising numerous
epidemiologic investigations to better explain mechanisms
of transmission, risk factors for infection and outcome. She also led the
development of CDC’s guidance on C. Auris detection,
management, and control. I’ll now turn to
over to Dr. Chiller. Dr. Chiller, you may begin.>>Great. Thanks, Kondra. It’s a pleasure to be here
and to talk to you all today. As mentioned, we’re going
to be giving you an update on multidrug resistant
Candida auris. So, we’re going to
follow an outline that was outlined as
well in the title. I’m going to give you a little
bit on current epidemiology and talk a bit about the
lab and identification, some management strategies, and
finally infection prevention. So, let’s talk a little
bit about the epi. As you know, this has
emerged both globally and now in the U.S. And I
think many of you, or some of you might have
seen some recent press on this in the New York Times. This was an article that
was written in April and highlighted some of
the issues and concerns that we have of Candida auris. So, the first case was
reported in the literature in Japan back in 2009. And subsequently, we’ve seen
spread, or at least emergence in identification in
many parts of the world. In the United States, we put
out an alert in 2016, and, of course, have now
identified it here as well. So, why do we care
about this weird fungus? Well, first of all, it’s
highly drug resistant. Second of all, patients
can become colonized and develop invasive infections or bloodstream infections
with this organism. And finally, it spreads unlike
any other Candida that we know in healthcare settings. So, this is really a paradigm
shift for Candida infections. And I like to say this is a
yeast that acts like a bacteria, resistant to the norm,
it thrives on skin, it readily contaminates patient
rooms and healthcare equipment. And because of that,
it actually spreads in these healthcare facilities. As I mentioned, it is
now a global issue. You can see here on this
map, we’ve now identified it in at least 30 countries, and obviously we haven’t looked
everywhere for it as well. So, I imagine it’s
in more than this. But one of the things
that’s been fascinating about the emergence of this
is that it really has came up in the last decade. Looking back at populations
of islets from prior to 10 years ago, it was
only identified once in 1996 in Korea and Japan. And subsequently,
everything really has come onto the scene in
the past 10 years. The other thing that’s
fascinating about that emergence
is that it appears to be four distinct clades or
types of fungi in this species that are emerging
at the same time. And you can see on this map that
there’s this real strong clonal of populations within these
four regions that seem to be carried throughout
the globe. So, just some examples of some
of the global epidemiology. Here’s a study that was done
several years back in India, one of the first places that
described Candida auris. This is looking at ICUs. Nineteen of them when they
started looking already had C. Auris, 5% of their
total Candidemias. And in some hospitals, up
to one in two of the cause of Candidemia was
actually Candida auris. South Africa also
has interesting and emerging information
on this organism. Here is a graph of surveillance
done in the past couple of years that shows that Candida auris is
now the second most common cause of Candidemia in
their private sector. And then if you look
at their public sector, which we would generally
think would not have access to as many antifungal drugs
as the private sector, you do now see that
it is emerging in their public sector
hospitals as well, being now the fourth most
common cause of Candidemia. Moving over to colonies in
Europe, it has been found in several different
countries in Europe, but this, this slide particularly
highlights a Spanish outbreak in a hospital. And you can look at the pie
graphs that show the breakdown of the different species
causing Candidemia. And you can see that
clearly before April of 2016, before this Candida
auris was identified, they had a pretty typical spread
of organisms of the species that you all see in the clinics. And then post April 20167,
when they got their first case, and subsequently their
next 150 plus cases, you can see Candida auris
made up the majority of the invasive Candida
infections, which is obviously rapid
and concerning spread of this organism
in that hospital. So, we were gathering a lot of this information,
as you all know. And in 2016, put out an
alert here in the U.S. And we actually found one
case that had been reported in a different surveillance
system, a bloodstream surveillance
system from 2013 in New York. But then after the first year of
putting this out, we did begin to identify more
cases and patients. And you can see the
majority were from New York. And then now we fast forward
to where we are today, or at least as of April of
this year, and you can see that we’re getting close
to 700 clinical cases, and around 1,900 patient
that are colonized with about 12 different
states reporting cases. Still, the majority remain
in three states; New York, New Jersey, and Illinois. This is just a breakdown of
that, that I just showed you, so a map depicting the
numbers of cases by state. So, let’s talk a little bit
about the risk factors then that we’ve found here in
the U.S. for Candida auris. And this slide really
sums it up. And it’s important to know that
the outbreak or the epidemic in the U.S. is really in
the sickest of the sick. Those super high risk patients that are quite medically
experienced. So, they can have
tracheostomies, often ventilator
dependent, often colonized with other multidrug
resistant organisms, clearly receiving antibiotics
or antifungals as a risk, as we know, for many
of these organisms. But I think it’s important to
note that in the United States, we don’t consider this a
threat to the general public or to healthy individuals. It is truly a problem within
these really sick patients that are quite medically
experienced. I think one of the things
that we are learning about this particular organism,
and I think it applies to some of the other multidrug resistant
organisms, is that stays in these post acute care
facilities are a major risk factor for the acquisition
and potential development of invasive infections. You might have heard the
terms vSNFs and LTACHs. That stands for ventilator
skilled nursing facilities and long term acute
care facilities. These are we are
finding sicker patients in these facilities
more commonly I think than we did even a decade ago. And in a recent look
that we did, we saw that the C. Auris
prevalence in nursing home units with ventilator beds was
around 8% versus the prevalence in regular nursing homes
with less than a percent. So, we’re concerned about
these particular facilities and have done a little bit
more looking into them. One of the things we know is that healthcare abroad is
a risk factor for C. Auris. Patients coming from places
where it is very endemic, like India and Pakistan, South
Africa, Kenya, Venezuela, and even places where it is not
it is still rare, but is found, are, can be at risk for
harboring this organism. Some of those patients in the
U.S. have been identified weeks to even years after that
hospitalization was reported in a particular risk country. And the ability to do the whole
genome sequencing has really allowed us to actually pinpoint where these patients’
islets are coming from. So, as I mentioned earlier,
there are four clades. You can see here if you
look at those four clades, every single islet in the
United States corresponds to one of those clades. So, we know originally they came
from one of these four areas. And so what about
importation into the U.S. then? [ Inaudible ] As I mentioned, every
single islet that we know in the U.S. is related to
one of these four clades, which originally comes from
different parts of the world. However, I think it’s
important to note that there were clearly original
introductions at some point in time, but then subsequently
followed by local spread. So, it’s not that all 600 of
the clinical cases are coming from healthcare abroad. They may have originated
from that, but they didn’t come from that. I think the next slide sort
of illustrates that point, that the majority of the
cases don’t have any link to direct healthcare because
they actually have linked to healthcare in
the U.S. Clearly, the result originally was from
some sort of local introduction. But now we really have local
transmission in those areas that have lots of cases. So, let me illustrate a bit
what it looks like in one of these ventilated
skilled nursing facilities that we had investigated with the Chicago
Department of Health. You can see here that
back in March of 2017, a point prevalence
survey result, so point prevalence survey
is when you sample all of the patients within
a particular facility or room or floor. So, one case of Candida auris in this particular facility
back in March of 2017. Seven months later, we had
suddenly a percentage of close to 43 or 45% positivity in
just a period of six, seven, eight months, just showing you
how this organism, once it sort of sets up shop in a particular
facility, can readily spread between rooms and
patients due to a lot of the interesting aspects of these ventilator
skilled nursing facilities. The other thing to note is that
they travel in packs it appears, because as you can see from this
graph in that same facility, Candida auris was often found with other multidrug resistant
organisms, meaning that, again, these ventilated skilled
nursing facilities can be a real harbinger for where these
organisms are hanging out. And a source then to
feed the hospital systems with patients that are at risk. One of the issues
then is colonization. And patients are often
colonized indefinitely. We’re not exactly sure
the timeline that we know of patients being
colonized for over a year. You can see here primarily
on the skin, but the nares and other body sites can
also become colonized. We don’t have any current
decolonization strategies that we know of. So, the other thing about
colonization that we often talk about is who cares,
what does it mean. Well, we know now that
colonization is a risk for invasive infections. And so we all worried about
patients being colonized for prolonged periods of time. I’m going to let Dr.
Vallabhaneni talk to you a little bit about
some of the more specifics of investigations
we’ve done in New York. Snigdha?>>Okay, thanks, Tom. And thank you, everyone,
for attending this webinar. As Tom said, one of the
key things to really know about in terms of risk
factors for Candida auris is that it really affects
the sickest of the sick. It’s the people who have had
extensive healthcare exposure, especially in long term care
facilities that take care of very sick people, such as the
long term acute care hospitals and the ventilated
skilled nursing facilities. And Tom also showed you how, how
much a facility can be burdened by patients who are
colonized asymptomatically. So, you wouldn’t know that
they had the colonization, yet it spreads to
other patients, and those patients can develop
invasive bloodstream infections where there’s a 40% mortality
once they develop invasive bloodstream infection. So, at CDC, and, you know, working with our state’s
health department partners, we wanted to figure out, you
know, what are risk factors for patients to get
colonized with Candida auris in these types of facilities, in these ventilated
skilled nursing facilities. And so we conducted
a case control study for C. Auris colonization
with, of course, a lot of help from our partners in New York. And what we’ve found,
what we found there is that these patients who are at the ventilated skilled
nursing facilities, not surprisingly, are very sick. They have a lot of
co morbidities. They have, a majority of
them, whether it was a case or a control, had
neurologic disease, many had cardiovascular disease
and diabetes, so very reflective of the type of patient that’s
at a skilled nursing facility. They were, they were
highly dependent for their activities
of daily living. So, they scored very
high on dependence. So, they couldn’t move without
assistance, were incontinent, and primarily fed
via a feeding tube. And that didn’t matter
if they were colonized with Candida auris or not. That was pretty similar
across both groups. But what we did see is
that having these devices, even though this was a
ventilated skilled nursing facility, not every
patient has these devices. And so having a tracheostomy,
being on, having mechanical ventilation,
and being fed with a PEG tube, often those three
things go together. Those were the patients
who were at highest risk for having Candida
auris colonization. And, again, we’ve talked
about antibiotic stewardship from CDC in many venues. But antibiotics used, especially
broad spectrum antibiotic use [inaudible] Vancomycin and
Meropenem were associated with risk of C. Auris
colonization as well. And then one of the others
things we noted in our study was that facility transfer,
so presence of multidrug, facility transfer and presence of multidrug resistant
organisms were, again, associated with C.
Auris colonization. So, many of these nursing home
patients who are going back and forth between the hospital and perhaps receiving
antibiotics for whatever reason they went to
the hospital for, were the ones who were, we were seeing
as being more likely to be colonized with
Candida auris, and having a multidrug
resistant organism, as Tom said, has borne out in
multiple studies that that is another risk
factor for Candida auris. Some of the reasons why C.
Auris really is able to spread like this, as we’ve seen on
these maps we’ve showed you, is that it can really survive
in the hospital environment. It’s been noted to be
viable even a month after a patient who’s
been in that room has left and the room has been cleaned. And really important to note is
that many, or at least one class of common disinfectants
used in hospitals, and these are called quaternary
ammonia compounds, or QACs, and these are very, very
commonly used in most hospitals and healthcare settings. They are not active against
C. Auris, at least not to the level we’d
like them to be. And so the persistence
in the environment and perhaps the right type of
disinfecting agent isn’t used, those two things, you know,
make colonization possible, and the spread and transmission
in these facilities possible. The other thing that’s
really important to note is that when you think of
environmental disinfection, we’re thinking about
cleaning the patient’s room and their bedside table, maybe
the handrails on their bed. But we’re often forgetting
about mobile equipment. With Candida auris,
several studies have shown that mobile equipment has
been heavily implicated in transmission. So, these kinds of
blood pressure cuffs and pulse oximeters and
thermometers and things that are moved from patient
to patient have been found to be contaminated and
thought to be responsible for spread between patients. One thing we noticed in our
study we did in New York is that the colonization
doesn’t seem to get past just your roommates. Everybody on the unit,
especially these high risk units with ventilated patients,
also seem to be at risk. So, you can see on this map
here, we checked everyone for colonization on this unit, and there are some roommate
pairs, the two reds in one room, but then you also see it’s
in other places in the unit where the roommates
aren’t colonized. And so this mobile equipment
kind of carries this bug around the facility and really,
you know, once it sets up shop, as Tom said, it’s
hard to get rid of it. The other thing I wanted to
mention also is that we have at least one case of Candida
auris that’s been documented to be transmitted through
organ transplantation. We had C. Auris culture
from lungs shortly after a transplant
in Massachusetts. The patient didn’t have
invasive Candida infection, but the donor alone was found to have Candida auris pre
transplant when we went back to look and the donor
was from Illinois. So, and the islet
was nearly identical to other Illinois islets. Really very strong evidence
for donor derived transmission. And we’ve had several
other cases occur in transplant patients, even
if it’s not been donor derived, due to transmission in
the healthcare setting. So, we’ve talked a whole bunch about risk factors
for Candida auris. We’ve talked, gone over
the global epidemiology and the U.S. epidemiology. Now we want to go into
identification and some of the challenges that you
all should be aware of. C. Auris detection has been
challenging because it is, you know, a newly
emerging yeast, not a lot of yeast
identification methods are able to identify it. But it’s getting better. There’s more awareness of
the organisms, you know, people know to look for it. There’s improved access to
MALDI TOF, which is a type of laboratory technology
that, you know, many labs are now using to do
not just yeast identification, but all kinds of identification
of microorganisms. And this helps improve the
accuracy of identification. Three years ago when we did this
call, hardly anyone was able to identify Candida auris, and now I think we’re
in much better shape. And then we also have the
ability to confirm Candida auris at reference and public
health laboratories. So, update on lab methods
on the CDC website, which resources are included
at the end of the slide set. We have a, keep a list of
all the types, common types of laboratory, automated
instruments that detect yeast
and identify yeast. And we now know that there’s
some types of instruments that are capable of accurately
identifying Candida auris. And FDA has approved
the VITEK MALDI, as well as the Bruker MALDI, and they can both accurately
identify Candida auris. VITEK 2 Version 8.01, if
you have that software, can accurately identify
Candida auris. And then we where is have a
real-time PCR that’s capable of identifying Candida auris. So, we keep this list of
misidentifications based on the identification method
used in your laboratory. Vitek 2, if you don’t have
the most recent software, then Candida auris can be
misidentified as other species, including Candida haemulonii. Same thing with BD Phoenix. Candida auris would come
up as Candida haemulonii. It’s important to know what
laboratory identification method your facility uses and what a
possible misidentification could be to be able to even suspect that you have a case
of Candida auris. Other challenges with
yeast identification where really mycology
labs are, you know, far and few in between,
and then what they are, what they do is also
not completely adequate for yeast identification. So, in many labs, yeast is not
determined to the species level, except by request, and
this is often only done for sterile site isolates. And for non sterile site
isolates like let’s say [unaudible] and urine, species is
often not determined because often it’s not
a clinical infection that requires treatment. But we would need to know
the species in order to know that it’s Candida auris, and
you’d have to take special steps to prevent transmission. And in the U.S., at least half, almost half of our
clinical cultures come from non sterile sites. So, we would be missing
all those cases if we didn’t do species
identification. So, we’ve tried out some
early detection strategies in several places in the U.S.
One specific long term acute care hospital network
decided to determine species of any yeast identified in
urine in any of their patients. Note that this is a
high risk facility, it’s a long term
acute care hospital. As we said, those are
places we see a lot of drug resistant bacteria, and we’re seeing a
lot of Candida auris. The yeast in this, in any
laboratory is generally tossed out because it’s not
considered an infection, the species isn’t determined. But once this laboratory
decided to take this approach, within five months, they
detected their first case of Candida auris
in their region, and really set off prevention
measures to contain the spread of this in their place. So, this is something
to consider if you work in one of these settings. Another approach people have
taken, and we recommend this from CDC, is that you
should screen patients who have had a history
of hospitalization abroad in the last 12 months. We’ve already talked about
how we know of 12 cases that have been imported
to the U.S. where we have known connections. We believe all of them,
you know, all of the cases that we currently have in the
U.S. were originally imported at some point, then followed
by local transmission. And so to prevent
that introduction, which has happened time and
again in multiple space, we recommend screening anyone
with hospitalization outside of the U.S. in the last
year, and especially if it’s in a country like
India, Pakistan, those ones that were
listed on the slide before, as well as we keep a map on
the CDC website to tell you which countries have been
associated with cases in the U.S., and if the patient
has a carbapenemase producing organism, like a CPCRE, or carbapenem resistant
Acinetobacter. Colonization screening
also presents challenges. As we said, patients can be
asymptomatically colonized. Right now, we have a PCR or a culture based method
that’s available through CDC and public health labs. But few clinical labs
are currently able to conduct this screening
for PCR, so any request for screening would need to come
through the health department to be able to be
coordinated right now. And this is a big challenge. And we’ve come a long way
in the last three years where we now have
a lot of capacity, at least in the public
health labs to do this. But eventually we hope this will
go to clinical labs as well. This is the public health lab
network I was referring to. Again, the website and active
resources for this are mentioned at the end of the slides,
slide presentation. But this is, this
is the network, the antibiotic resistance
laboratory network that’s available free of cost for Candida auris
identification services. And that includes
both confirming islets and conducting screening tests. And then the last thing
for identification is that C. Auris became nationally
notifiable last year according to CSGE. And so now in many states,
C. Auris is reportable, and that means when a laboratory
suspect or identifies a case of Candida auris, it
should be reported to the local health
department based on the local jurisdiction rules. And I’m going to hand it back
over to Tom for a brief talk about the management
of C. Auris.>>Thanks. So, continuing along,
one of the challenges with treating invasive fungal
infections, as many of you know, is that we’re limited
on the number of antibiotic classes
we actually have. And we only have three classes
really of any fungal medicines. The Azoles, the Polyenes,
and the Echinocandins. And for Candidemia, first line
there are the Echinocandins. And we routinely use those
now over the past decade and a half year to
treat Candidemia with a lot of success. If we look in general at
resistance, we like to think of resistance for Candida auris
in that almost all, close to 90% of resistance to Azoles, or
Fluconazole in the Triazoles, about a third, which is very
rare for Candida species, are resistant to the
Polyenes, or Amphotericin B, and thankfully still a
very small percentage, somewhere below 5%,
are resistant to our first line
therapy, Echinocandins. So, we still want and encourage
everyone to use an Echinocandin when they’re treating
Candidemia. I think that there are going to
be potentially some challenges in the future if
resistance continues to evolve in these organisms. About a third of them are MDR,
so they have their two or more, two really, two, they’re
resistant to two drugs. And then we have had
two islets in the U.S., and there have been
several other countries that have reported these that have been resistant
unfortunately to all three classes. So, as I mentioned, Echinocandins are still
first line treatment, and the good news is resistance
to that remains very rare. We do want antifungal
susceptibility testing done on every islet. And, in fact, the [inaudible]
guidelines recommend that for Candidemia in general. Similarly to Candidemia,
you want to repeat cultures until they are negative so
that you document the infection has cleared. So, let’s talk about
pan resistance, because honestly that’s
really concerning to us here. This is what all three
classes exhibit, higher MICs, and we have confirmed
pan resistant islets in New York now. There have been two. Both these cases were unrelated. And concerning is that
they developed Echinocandin resistance on Echinocandin
therapy. They were already resistant to
Fluconazole and Amphotericin. And, you know, that’s
obviously disconcerting because that’s a real challenge. And it just speaks to using
these drugs judicially with the right dose and for
the right amount of time. But it also speaks to really
monitoring our patients on C. Auris and treatment
because this bug likes to become resistant, and it has
readily developed mechanisms to acquire that resistance
rapidly. In these particular cases, we
didn’t see any transmission, and there has been no
further identification of pan resistance, although
it has been reported from several other
countries around the world. I think one of the
good news things about management is there
are some new antifungals. And this is just a short list
of a few that are out there. And the other good
news is that some of these have new
mechanisms of action. And honestly that’s what we
need in both the antibacterial and antifungal world
is some new drugs that target different
parts of the organisms. Next? And I highlight just
a couple of these that are in clinical trials, safe
in humans, moving in both to phase 2 and phase 3. Both of these drugs work well
in the test tube at least against Candida auris. And I think if we encounter
more pan resistance, we may need to be
going to these drugs on a compassionate use basis,
and so that’s why I wanted to mention them to you
today on this call. Next slide? Decolonization, as
Snigdha mentioned earlier, is a real challenge. Patients are heavily colonized. And as we all know,
decolonizing or source control on skin is a challenge
for many organisms, but we are working toward
ideas in which we might be able to render someone essentially
C. Auris free using different decolonization techniques. But those techniques and
methods still remain to be seen. So, we mentioned it
already once, but, again, we can’t say enough about
antibiotic stewardship. You know, I always like to say that if you give
an antibacterial, then you kill all the
good and bad bacteria, but you select for
all the fungi. And if you give the wrong
antifungal, then you may select for a resistant fungus. And so really stewardship in the fungal infection world
considers both antibacterials and antifungals, and I think we
really need to be thinking hard about how we use these drugs when we’re using
the dose, et cetera. So, for both fungal and
bacterial infections, I think how we steward
these drugs is really key. So now I’ll turn it back
over to Snigdha to finish out with some comments
on infection prevention.>>Okay, so we’ve talked so far
about the global epidemiology, risk factors, we talked
about how and why it spreads in healthcare settings
and how to treat it. But what I’d like to do now is
go over a few key principles of how to prevent the
spread of this organism. And what’s interesting is that
it’s really back to basics. It seems like this strange
new [inaudible] evolved and emerged here. But really the main
things that we need to do to prevent its spread
are not rocket science. It’s things that all of us in the clinical community
are very aware of. And that includes hand
hygiene, number one. Number two, protective,
personal protective equipment and precautions. And that, for C. Auris,
is contact precautions. That includes gown and gloves. And then as we mentioned
already, because of its propensity to
contaminate the environment and persist there, it’s
environmental cleaning and disinfection,
including mobile equipment. So, these are things that
many of us are familiar with that we do for C. Diff,
for, you know, many other types of organisms that patients might
come into the hospital with. Hand hygiene, again, this
is, these are reminders. We at CDC, alcohol based hand
rub is preferred over soap and water except when
hands are visibly soiled. So, we highly encourage the use
of hand hygiene, and, you know, all the moments that are
necessary for hand hygiene; before and after patient care, before and after
touching equipment, before and after donning
and doffing gloves. And it’s important to
remember that you need to apply the product to one
hand and then rub them together until it covers all surfaces. And it ideally should take
20 seconds to do this. And many of us are
very busy clinicians and need to run around. But this is a life saving
intervention for patients. Next thing again, just emphasize that contact precautions
are recommended for patients who are colonized or
infected with C. Auris. Gowns and gloves must be
worn on every room entry and then removed before taking
care of the next patient. And environmental cleaning and disinfection product
must have must be active against C. Diff spores. So, that’s what we’re
saying right now, because we don’t have a specific
indication for Candida auris for many of these agents. EPA provides a list,
it’s called List K, that has antimicrobial
activity against C. Diff. The CDC also maintains, on our
website, we have recommendations on what product can be used
to clean the environment that has suspected C. Auris
or confirmed C. Auris. And that, it can be some
products that are not on List K, but that’s the primary
source to go to to know which products are used to
disinfect your environment. And then in some
places, we’ve considered, we’ve recommended considering
using it across the entire unit if multiple residents
with C. Auris are found. And then focusing the
environmental disinfection on bed and chair rails, sink
and toilet, bedside tables, call lights, and, you
know, any of these like high touch surfaces. And then, of course, disinfecting shared medical
equipment, dedicating them when possible when a patient
is on contact precautions, and for things that
can’t be dedicated to clean and disinfect them. And then make sure that
staff knows who cleans what so that the devices don’t
get used and then left there without being cleaned
because that can really potentiate transmission. And then, you know, of
course, if you have a patient with Candida auris, it’s
really important, as we said, many of these are nursing home
patients, they’re either coming from a nursing home or
leaving to go to a nursing home or a long term acute
care hospital, and it’s really important
to communicate their status at the time of transfer. CAV has resources for this. There’s an inter facility
communication form that tells the receiving
facility what organisms the patient may have and what
types of precautions may need to be taken, infection control
precautions need to be taken. And then containment steps when
a case of C. Auris is found, really the first thing
to do when you suspect or have a confirmed case of
Candida auris is report the case to your local or state
health department. And with the help of the
health department, you know, they would guide you in this,
but screening other patients who are in contact with
the [inaudible] patient that identify asymptomatically
colonized individuals. And as we showed earlier, this may not just be
limited to roommates. It may be other people on the unit conducting infection
control assessments to make sure that people are complying
with hand hygiene, with contact precautions, and the environmental
disinfection piece. And then conducting meticulous
prospective surveillance to pick up other cases if they’re
happening in your facility. And then we work very often
with health departments to say, you know, C. Auris
has been not something that causes outbreaks
in a single facility. Often, it’s easily
spread to other facilities because patients are
moving back and forth. And so we work with
health departments to assess other high risk
facilities in that area to look for asymptomatically
colonized patients. I just, I’ll just
say one wrap up word about infection prevention, which is that it’s really
infection prevention. You’ll never know, despite
early detection strategies, you’ll never know when a
patient with Candida auris or another multidrug resistant
organism is entering your facility or who you’re
taking care of. And so it’s really,
it’s a preemptive piece, making sure your hand
hygiene is up to par, and making sure your infection
control measures are really in place so that if you do
have a patient like this that enters the facility,
that doesn’t spread and put other patients at risk. So, I’m going to hand it over
to Tom to wrap up the talk.>>So, in conclusion,
this is a new bug, but it’s using old tricks. It’s resistant, highly drug
resistant in some patients, cases, can be invasive
and make people sick, and even cause mortality. And it’s spreading
readily in facilities, in healthcare facilities. And this is similar to some
of the other bugs that many of us have been dealing with
now for a while; CRE, VRE, MRSA, and other resistant organisms. We’re obviously still learning
about this particular organism, which is a fungus, although
I like to say it’s a fungus that acts like a bacteria
so that we all think about it in that term. I think the good news here
is that the principles because of that, of infection
control and management that we’ve just talked
about, apply. And we’ve had success stories. We’ve had facilities
that have had cases, and even small outbreaks,
and have gotten rid of it, and it is no longer appearing. So, people always like to ask us in interviews what
keeps us up at night. And I guess one of the things
that really concerns us is that Candida auris leaps ahead of all these other
common Candida and Candidemia causes
that, you know, are really major concerns
in the United States. So, Candidemia is a major cause of bloodstream infections
in our ICUs. In fact, in some studies,
it’s the number one cause. So, what concerns us is if a Candida auris became a
common part of that [inaudible]. And so far, it’s not, but I
think we’ve given you examples in other countries where
unfortunately it is. Some other concerns would
obviously be the idea of pan resistance. It’s here. We really need to control
that and control that and control that spread. The inability to identify
Candida auris has been improving rapidly. And so we feel like we
have a much better handle on where Candida auris is, and that facilities can get
their Candida identified as they need to. And then finally we
talked a lot today about these long term
acute care facilities. And the challenges I think we’re
really going to have moving into the future with these
facilities being harbingers of these multidrug
resistant organisms. So, what should you do next? Ask your laboratory
some questions, make sure that you are using
some way to identify yeast, can you detect C. Auris,
what do you do to inform when you do find C. Auris. If you’re admitting patients with hospitalizations outside
the U.S. in the last year, especially if they have
carbapenem resistant organisms, think about screening for
Candida auris as well, so work with your health
departments to do that. If you’re seeing a patient
with C. Auris infection, make sure that they are
in contact precautions, request antifungal
susceptibility testing, treat empirically
with Echinocandins, and get an ID consult. And finally, do your part
with infection control. Hand hygiene, hand
hygiene, hand hygiene. Here are some resources
that we have that will obviously be
included in the slide set. And we’ll turn it back
over to the COCA folks to help administer questions. Thanks very much.>>Thank you so much, Dr.
Chiller and Dr. Vallabhaneni for providing our audience with
such a wealth of information on this important
public health topic. We will now begin
our Q&A session. Please remember, you
may submit questions through the webinar system
by clicking the Q&A button at the bottom of your screen
and then type in your question. Again, please do not submit your
questions using the chat button. Questions submitted in the
chat button will not be seen. Okay, so we have a couple
of questions that have come in through our webinar system. So, now for our first question,
is CGH effective on C. Auris? I’m sorry, CHG effective
on C. Auris?>>CHG, yeah, is CHG,
that’s a great question. And, you know, there have been
some places that have used CHG in a very aggressive format. So, CHG is Chlorhexidine. And as you all know, it’s a very
common anti really microbial because it does have
activity against fungus and bacteria that’s used
on the skin and bathing and in the nares of patients. We are still looking into it. There have been some in
vitro data to suggest that it does work
against C. Auris. And then there’s been
other testing that’s done that doesn’t show that
it works all that well. I think it may come down to
when it comes to decolonization and treating patients and decolonizing them
is how well you use it and how often you use it. I think we’ve found that many
times facilities will, you know, use CHG, but maybe not in the
best way, or not use it enough, or not apply it in the
most appropriate way. So, I think the short answer
is the jury is still out as to whether CHG will
be an effective way to control Candida
auris on the skin.>>Thank you, Dr. Chiller. Next question. Have any studies been done
to see whether caregivers and healthcare providers
are colonized with C. Auris?>>Yeah, thank you. Another great question. We have done a little bit
of work looking at the hands of healthcare workers in
a couple of these settings where we’ve investigated
outbreaks of Candida auris, and including colleagues in the
UK have also done work on this, and interestingly enough,
yes, you can find it on healthcare workers’ hands. That’s about all we’ve
really tested so far. But it is relatively rare. And so we’re certainly
not seeing it, at least in the few
times we’ve been looking, we’re certainly not seeing
it in large percentages, suggesting that if
there is a component of healthcare transference
via healthcare workers, it doesn’t seem to
be a prominent way in which it is being
transmitted, you know, but again, those are hard
studies to do oftentimes to get cultures of
healthcare workers’ hands and get them in different ways. You know, thankfully
there’s a lot of good hand hygiene going on, a
lot of glove wearing, et cetera, so, so, so, we’re not sure the
contribution to, you know, for, from healthcare workers in
this transmission cycle. But, again, it has been
done, it has been found, but it’s been relatively rare.>>Thank you. Next question. Are we seeing an increase due to
better lab detection as opposed to a true rise in cases?>>Another great question. Good that you have your
epidemiology hats on. We are, we are not
seeing an increase due to better lab detection as far
as sort of an absolute increase. Certainly, some of the numbers
that you see on the website, because we’re reporting
every islet we have, are related to the fact that
we’re going out and looking for it more and doing these
point prevalent surveys and we’re identifying it. So, I’ll imagine if it’s broader
and there are more islets or patients colonized out
there than we are identifying, but we don’t think that
this is simply just an identification artifact. We do, indeed, think it is
spreading, and is increasing, and that’s largely because
we’ve seen that in other places around the world, and we know that that’s what
this organism does. It tends to set up shop, like
you saw in some of the slides with the ventilator
skilled nursing facilities, and then in a very
short period of time, can be found widespread
both in that facility and amongst patients
in those facilities.>>Thank you. Are there recommendations for
bathing patients with C. Auris?>>This is Snigdha. I’ll answer that question. So, we recommend routine bathing
to continue the procedure, policies and procedures
that the facility has. I know the question of CHG came
up, and we don’t recommend for or against CHG for C. Auris since we don’t know what
the impact of that is. We just recommend, you know,
good hygiene for patients. We think, you know,
it’s effective, it’s not specific to C. Auris.>>Thank you. Next question. Have we seen C. Auris spreading
in the community as well?>>Yeah, the community
question is a good one. We are not actively
looking in the community because we are busy
looking really in the healthcare facilities. As I’ve mentioned already, in
the U.S., we are not concerned about community infections or the healthy people
getting Candida auris. Whether there can be carriage in the community,
we still don’t know. There are some groups
actively looking into that, and hopefully we’ll have
more information on it. But, again, our concern really
is in healthcare facilities, and because it is
affecting those very sick and vulnerable patients, we
want to be able to eliminate it from there, and then we
could be looking more at the community element
into those introductions.>>Thank you. Next question. Can you elaborate on
the recommendation of alcohol based hand
rub or handwashing?>>Yeah, this is Snigdha. So, I’ll address that. And I know that people,
because we’ve talked about the environmental
disinfectant being one that’s active against C. Diff,
and many times for C. Diff, the practice is to use soap
and water for hand hygiene. That is not necessarily
the case for Candida auris. It’s alcohol based hand
rub is very effective at eliminating Candida
auris from hands of healthcare workers,
or, you know, anyone. But specifically healthcare
workers is what we’re concerned about. And so that’s what we recommend. Of course, soap and water
should still be used when hands are visibly soiled.>>Thank you. Next question. What should I do if my lab
doesn’t routinely identify the species of Candida?>>So, we have resources now to help identify suspect
cases of Candida auris. As I’ve said, there
are public health labs, regional public health labs through the antibiotic
resistance laboratory network funded by CDC that will be able to narrow once the
clinical lab has narrowed it down to a certain species
or may misidentification, then the public health
lab can take that and say whether it’s
Candida auris or not. You know, if the
clinical lab doesn’t, doesn’t determine the species
at all, I think, you know, that’s hopefully a place that
an administrator can address, because that’s really
needed for clinical care. Every lab should be
able to identify species at least upon request. And that’s needed for
routine patient care, let alone Candida auris. But if they can identify,
you know, at least rule out the Candida albicans or
bring it down to a certain level where there’s some species
on identification done, then the antibiotic resistance
laboratory network labs can assist with further
identification.>>Thank you. Would one case of C. Auris
be considered an outbreak in a facility where C. Auris
was not previously identified?>>This is Tom. I can turn this to
Snigdha as well. But, yeah, we consider a
single case as being a, whether you want to call
it outbreak or an issue or a concern, yes, we
consider that one case, considering we don’t know
where that case came from, considering we don’t know
whether it’s already spread into the environment. So, a single case is enough
to trigger an investigation on our part or working
with a state or a local health department.>>Thank you. Next question. What body sites are screening
for C. Auris colonization, and how can I access C.
Auris colonization testing?>>This is Snigdha. That’s an excellent question. And what’s interesting
is we found about Candida auris
that’s different from the other Candida species,
which generally are known to colonize the gut, is that Candida auris is much
more likely to be on the skin and nares; primarily the skin
[inaudible] groin are the places we use. So, we swab the [inaudible]
and groin to identify patients who are colonized with C. Auris. And, you know, colonization
screening isn’t being done in clinical laboratories
for the most part, although there are
hospitals, you know, in these higher prevalence areas
that are trying to do this, but the way to do the
colonization screening is to get in touch with the local and
state health department there, their healthcare associated
infections program. And those resources are
available on the ARLN website that are in the previous slides. And they would help coordinate
testing through the state, on the state public health labs.>>Thank you. Next question. Is C. Auris airborne?>>Well, we do not
know, but we don’t think that it is a major issue with
this particular organism. You know, I think that
many fungi are airborne, and we do worry about fungi
in spores being inhaled. With this particular bug,
we think it’s probably more of a skin and a skin
cell spread. So, as we shed our skin
cells, that they spread out into the environment. In some early data that
we’re looking at seems to correlate a higher
burden of organisms on skin correlates well
with a higher burden on the immediate
environment of that patient, suggesting that there is
some sort of a relationship to skin cell shedding. So, we think probably
we’re dealing more with that type of transmission. There has been no documented
airborne sort of transmission with this organism, you know, and so we’re not
concerned about that. But it’s still an area
that we are always looking at because fungi are readily
transmitted in the air for other types of species.>>I’ll just add that
it’s not the kind of thing that I would worry
about, you know, catching on an airplane
or on a public bus. This is really something
that’s transmitted in the healthcare setting
by mobile equipment and healthcare worker hands, you
know, the usual ways that a lot of these pathogens
are transmitted. But no need to wear masks
and worry about it on a bus.>>Thank you. We have time for
one more question. If I’m in an area that
has not seen cases yet, what are the main things I
should be doing right now?>>We want to increase
detection capabilities. And the earlier we find
cases of Candida auris, the more we’ll be able to
intervene and prevent spread. And so I think one of the
key things is really talking to the laboratory. Or if you’re a laboratorian, to understand what yeast
identification methods are being used, and if you can
identify Candida auris or not. And if not, what
steps can you take? Where can you send that islet? Who can you talk to
to make sure yeast is identified appropriately? That’s number one is detection. And then number two,
as I mentioned in the infection prevention
section, I think it’s really about preempting this. You will never know, even
with early detection, when you will have
a case of this. And taking the opportunity,
taking the threat of C. Auris coming to
this area as a reason to improve hand hygiene,
to improve adherence to transmission based
precautions, whether it’s for flu or TB or whatever it is
in your hospital, doing that. And then number three, making sure that environmental
disinfection is up to par. And there are infection
control practitioners in your facilities,
so you’re not one to help do these
types of things. And then, of course,
communicating any type of multidrug resistant organism to the next facility that’s
receiving the patient. I think these are things
that can be done by anyone, so that figuring out what
the detection capacity is, and then preemptively making
sure infection prevention measures can be as good as
possible to prevent transmission if a case were to occur.>>Thank you so much. If we did not get to
ask your question today, you may e mail your question
to us at [email protected] Again, that is [email protected] And we will get a
response back to you. On behalf of COCA, I would
like to thank everyone for joining us today,
with a special thank you to our presenters, Dr.
Chiller and Dr. Vallabhaneni. The video recording of
this call will be posted within the next few
days to the COCA website at emergency.cdc.gov/coca. Again, the web address is
emergency.cdc.gov/coca. All continuing education for
COCA calls are issued online through TCE Online,
the CDC Training and Continuing Education Online
System at www.cdc.gov/tceonline. Those who participated in
today’s COCA call and would like to receive continuing
education should complete the online evaluation
by July 22nd, 2019, and use course code WC2922. Those who will review the
call on demand and would like to receive continuing
education should complete the online evaluation between
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and have a great day.

3 Comments

  • Reply pleiades drew July 5, 2019 at 8:22 pm

    CDC is for vaccines because they make money.
    Hope they can accept the fact that they covered up the damage caused by shots. The healthy child needs no poison in their blood stream.

  • Reply Feniter July 18, 2019 at 10:52 am

    I really hope somehow it will be eradicated before 2020..

  • Reply OGASI July 26, 2019 at 9:56 pm

    so you released something, or are about to?

  • Leave a Reply