Disease Debrief: Candida auris

Updated on August 20, 2019

NCCID Disease Debriefs provide Canadian public health practitioners and clinicians with up-to-date essential information on prominent infectious diseases for Canadian public health practice. While not a formal literature review, information is gathered from key sources including the Public Health Agency of Canada (PHAC), the USA Centers for Disease Control and Prevention (CDC), the World Health Organization (WHO) and peer reviewed literature.

Questions, comments and suggestions regarding this debrief are most welcome and can be sent to Sheikh.Qadar@umanitoba.ca.

Candida auris infection is difficult to diagnose, and missed diagnosis may lead to spread. It is difficult to treat, and its multidrug resistance also leads to concern of further transmission. There is a high propensity for outbreaks. All of these factors make C. auris a public health concern.

Clinicians in Canada should check for and review any protocols or guidelines on C. auris written for their province or territory.

What are important characteristics of Candida auris infection?

Cause:

  1. auris is a globally emerging yeast-like fungal pathogen related to Candida albicans. It is a rapidly emerging cause of hospital acquired multidrug resistant fungal infections. These infections can be superficial such as skin infections, or invasive such as blood infections. Colonization and overgrowth have been identified as the source of invasive infections.
  2. auris infections have mostly affected hospitalized or immunocompromised patients. Invasive infections with any Candida can be fatal. Crude mortality rates of approximately 30-60% have been reported for C. auris (1).

 

Signs & symptoms:

  1. auris infections may present similarly to other Candida spp., ranging from colonization to localized infections, such as otitis media and externa to bloodstream infections and sepsis syndromes.

Common symptoms of C. auris infection are fever and chills not improving after antibiotic treatment for a suspected bacterial infection. Recently hospitalized patients who have had a central venous catheter or other lines or tubes entering their body, or who have previously received antibiotics or antifungals appear to be at a high infection risk. In addition, travelers who have been hospitalized while outside Canada, including medical tourists, could be at risk for C. auris.

Metastatic complications like spondylodiscitis, endocarditis and ventriculitis have been associated with C. auris. Involvement of respiratory, urogenital, abdominal, skin and soft tissue sites have been reported as well.

 

Transmission:

  1. auris can be transmitted in healthcare settings, including long-term care facilities, after contacting contaminated surfaces or equipment or from person-to-person contact. Previous experience suggest that multi-drug resistant (MDR) C. auris may contaminate the environment of a room of colonized or infected patients.

 

Infection prevention & control:

Clinicians in Canada should check for and review any IPC guidelines on C. auris written for their province or territory.

Identified cases of C. auris should be placed into a single room with dedicated toileting facilities. Hospital staff should wear protective equipment such as gloves, long sleeved gown, surgical mask and eye protection, with a high emphasis on hand hygiene, and caution in intra- and inter-facility transfer of patients and environmental cleaning. Appropriate infection prevention and control protocols and environmental cleaning can help prevent transmission in healthcare settings.

Nosocomial outbreaks are expected as patients remain colonized or environments can remain contaminated for weeks to months after infection. Multi-use axillary thermometers and blood pressure cuffs were associated with large-scale hospital outbreaks in the United Kingdom (UK) and Spain.

Surface cationic-active disinfectants and quaternary ammonium disinfectants are ineffective against C. auris. In addition, C. auris is relatively resistant to ultraviolet light. However, chlorhexidine gluconate, iodinated povidone, chlorine bleach and hydrogen peroxide vapour appear to be effective against C. auris.

 

Diagnostic challenges:

“C. auris can be difficult to detect by routine laboratory testing. This may lead to delays in identifying and isolating colonized or infected patients.”(1)

C auris is difficult to diagnose. It can be identified accurately using matrix-assisted laser desorption ionization time-of-light (MALDI-TOF) mass spectrometry instruments with databases that include C. auris and by molecular-based sequencing methods. Commercial biochemical identification systems commonly used in clinical microbiology laboratories are unreliable for C. auris identification.

 

Case investigation:

Upon identification of C. auris, every case requires immediate investigation to determine the probable source and risk of transmission within the facility. Patient or residents who test positive for C. auris, including prior hospitalization or receipt of health care (e.g., dialysis, day surgery) at a Canadian health care facility where C. auris transmission has occurred, or a health care facility outside Canada, should be identified for C. auris risk factor acquisition.

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What to Do to Detect and Manage Candida auris?

Source: Schwartz, Smith and Dingle, 2018. Something wicked this way comes: What health care providers need to know about Candida auris. Canadian Communicable Disease Report 2018 44(11). Table 2

Public Health Ontario-January 2019-Case investigation

What to Do How
Abbreviations: C. aurisCandida auris; CDC, Centers for Disease Control and Prevention; US, United States
Keep a high index of suspicion Consider C. auris in patients who:

  • received health care in countries (or US states) where C. auris is prevalent, as tracked by the CDC
  • have a clinical syndrome consistent with candidiasis and fail to respond to empiric antifungal therapy and from whom an atypical or unidentified yeast is isolated
Assess for C. auris specifically Consult with a microbiologist and/or infectious disease specialist

Refer suspicious or confirmed isolates to relevant provincial laboratory for further testing or for referral to the National Microbiology Laboratory

Manage C. auris with a robust clinical infection control and public health response Notify the institutional infection prevention and control team

Notify local public health officials, who will notify their provincial/territorial counterparts (who will notify the Public Health Agency of Canada)

Place patient in single room with contact precautions in addition to routine practices

In case of symptomatic disease, begin treatment, preferably with guidance from an infectious disease specialist (treatment of asymptomatic colonization is not recommended)

Order daily and terminal cleaning of the patient’s environment with sporicidal disinfectant

Enable local public health officials to initiate contact tracing and screening to assess for C. auris transmission

Order composite swab of axilla and groin when indicated for patient screening

 

Treatment & management information:

Treatment for C. auris is problematic because of its antimicrobial resistance. Isolates are less susceptible to antifungals than other Candida species, although patterns of susceptibility appear to be related to the geographic clade. More than 90% of strains are fluconazole–resistant, about 30-40% are resistant to amphotericin B, and between 5-10% have been echinocandin resistant.  Resistance to two antifungal classes occurred in 41% of global isolates tested. In rare cases, isolates can be resistant to all three major classes of antifungal agents.

Please see: Canada Communicable Disease Report-volume 44-11-Something wicked this way comes: What health care providers need to know about Candida auris-Section on treatment challenges

 

Epidemiology:

The first case of Candida auris was reported in 2009 in Japan in the ear of an infected patient. Since then, it has been reported in at least 30 countries on six continents.

In Canada, the first known case of multidrug-resistant Candida auris was reported in July 2017 in an individual who had a two-year history of recurrent ear complaints after a trip to India that included hospitalization for a brain abscess following oral surgery.

There is reason to believe that warming temperatures as an aspect of climate change are contributing to the spread of C. auris (2).

What is happening with current outbreaks of C. auris infection?

According to the Public Health Agency of Canada, about 20 cases of C. auris were reported between 2012 and June 2019,  of which six cases were in Central Canada (Quebec or Ontario) between 2012-2017,  and14 cases were in Western Canada (Manitoba, Saskatchewan, Alberta or British Columbia) between 2014 and June 2019.

 

Reporting:

According to the latest federal description of C. auris in Canada, clinicians should notify the institutional infection prevention and control team and the local public health officials who will then notify their provincial/territorial counterparts, who are then responsible to notify the Public Health Agency of Canada.

Clinicians in Canada should check for and review any protocols or guidelines on C. auris written for their province or territory.

In addition, the Public Health Agency of Canada “would appreciate being informed of any additional cases of confirmed C. auris infection (both drug resistant or not) via email to CARS-SCSRA@phac-aspc.gc.ca

See slide 16 here: Public Health Agency of Canada communication notice-Emerging global healthcare associated infection-Antimicrobial resistant issue-Candida auris

In the U S, C. auris is a nationally notifiable condition and is reportable in many states. Once identified, laboratories should report cases immediately to the state or local health department and to CDC.

CDC-Surveillance for Candida auris

 

References

  • Schwartz IS, Smith SW, Dingle TC. 2018. Something wicked this way comes: What health care providers need to know about Candida auris. Can Commun Dis Rep 2018; 44 (11):271–6. https://doi.org/10.14745/ccdr.v44i11a0
  • Casadevall A, Kontoyiannis DP, Robert V. 2019. On the emergence of Candida auris: Climate change, azoles, swamps, and birds. mBio 10:e01397-19. https://doi.org/10.1128/mBio.01397-19
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