Update: Candida auris in Orange County

July 02, 2019
Patients colonized or infected with Candida auris ( C. auris ) continue to be identified in Orange County.

Point prevalence surveys, with testing of all residents of a facility, have been completed in all long term acute care hospitals (LTACs) and skilled nursing facilities that provide ventilator (vSNFs) in Orange County. Multiple LTACs and vSNFs were found to have patients who are C. auris colonized. Over 100 colonized patients have been identified thus far. Several facilities had no colonized patients identified, and some facilities who initially had colonized patients identified no longer have evidence of ongoing C. auris spread.

In communities experiencing C. auris outbreaks, colonization and disease rates have consistently been highest in residents of LTACs and vSNFs.  However, C. auris transmission has likely occurred in a variety of healthcare settings during this event. Appropriate infection control measures should be taken by healthcare providers in all settings.

OCHCA is working with all facilities where C. auris -colonized patients have been identified to assure that receiving facilities are informed of the situation when patients are transferred. 

Updated recommendations for healthcare facilities receiving patients from LTACs and vSNFs with potential ongoing spread of C. auris :

  • Hospitals should institute empiric Standard and Contact Precautions.
  • Skilled nursing facilities should institute either empiric Contact Precautions or Enhanced Standard Precautions, depending on the clinical status of the patient and the C. auris epidemiology of the facility.

  •  Admission screening for C. auris should be performed by receiving facilities for all patients who may be admitted for a prolonged period (one week or longer) from facilities with potential ongoing C. auris spread.
  • Admission screening for C. auris should include a composite swab of the axilla and groin. 
  • Screening of nares for colonization has been found to add little sensitivity to axilla and groin swabbing and is no longer recommended.
  • Patients who have been previously screened at a facility with C. auris-colonized patients should still have admission screening performed at the accepting facility.   
  • Culture testing for C. auris colonization is available through the Centers for Disease Control and Prevention (CDC) and takes 7-21 days to result. 
  • Receiving facilities should contact OCHCA at 714-834-8180 to arrange for receipt of screening swabs and to coordinate their transfer to a public health laboratory for testing.

  • Facility-to-facility communication is critical when transferring a patient who is suspected or confirmed to be colonized or infected with C. auris. Any receiving facility should be made aware of the patient’s status.
  • Hospitals that frequently share patients with Orange County LTACs and/or with vSNFs where C. auris-colonized patients have been identified are currently recommended to perform species identification of all clinical Candida isolates, regardless of specimen source. OCHCA has contacted the affected facilities regarding this recommendation. Enhanced Candida speciation will help assure identification of C. auris. No additional surveillance or infection control measures are recommended for these hospitals at this point.  
Background:
Candida auris is an emerging yeast that is multidrug resistant and has a propensity to spread in healthcare settings.  C. auris is an emerging yeast that is multidrug resistant, can cause serious invasive infections and has a propensity to spread in healthcare settings.  Patients at highest risk are those who have been hospitalized long-term, are ventilated, have a tracheostomy, have an indwelling intravenous catheter, and/or have received multiple rounds of antibiotics.   Early detection of C. auris and rigorous adherence to infection control measures is essential for containing its spread in healthcare facilities.   

Outbreaks have occurred in several states, primarily in the eastern half of the country. This cluster of cases is the first seen in Southern California.  Early detection of C. auris and rigorous adherence to infection control measures is essential for containing its spread in healthcare facilities.
Infection Control: 
Appropriate infection control precautions for patients admitted to acute care hospitals who are suspected or confirmed to be colonized or infected with C. auris include:
  • Place patient in a single-patient room and use Standard and Contact Precautions.
  • Emphasize adherence to hand hygiene.
  • Use dedicated medical equipment.
  • Minimize the number of healthcare staff caring for the patient.
  • Clean and disinfect the patient care environment and reusable equipment (daily and terminal cleaning) with recommended products (see Cleaning Agents section below) throughout the unit or facility where patients with C. auris are located. 

Patients will generally remain colonized for several months, even after an active infection has resolved. The maximum amount of time that a patient can be colonized is unknown. There are currently no data on the efficacy of decolonization for patients with C. auris , such as the use of chlorhexidine or topical antifungals.

Suspected or confirmed colonized patients that are admitted to skilled nursing facilities can be cared for using Enhanced Standard Precautions in most instances. See: https://www.cdph.ca.gov/Programs/CHCQ/LCP/CDPH%20Document%20Library/Enhanced-Standard-Precautions.pdf for further details on enhanced standard precaution principles.

Additional infection control recommendations for a variety of healthcare settings can be found at https://www.cdc.gov/fungal/candida-auris/c-auris-infection-control.html .

Laboratory Testing:
C. auris has been identified from many body sites including bloodstream, urine, respiratory tract, biliary fluid, wounds, and external ear canal. The CDC recommends that all yeast isolates obtained from a normally sterile site (e.g., bloodstream, cerebrospinal fluid) be identified to the species level so that appropriate initial treatment can be administered based on the typical, species-specific susceptibility patterns. In addition, yeast isolates obtained from non-sterile sites (e.g., urine, respiratory tract) can be identified to the species level as part of enhanced surveillance for C. auris .
Cleaning Agents:
CDC recommends the use of an Environmental Protection Agency (EPA)-registered hospital-grade disinfectant effective against Clostridioides difficile spores (List K, found at https://www.epa.gov/pesticide-registration/list-k-epas-registered-antimicrobial-products-effective-against-clostridium ). Quaternary ammonium compounds that are routinely used for disinfection may not be effective against C. auris , and data on use of hands-free disinfection methods, like germicidal UV irradiation, are limited. 
Treatment:
Consultation with an infectious disease specialist is highly recommended for patients infected with C. auris .  Echinocandins should be used for initial treatment in most cases.   C. auris isolates from Orange County cases have thus far been susceptible to caspofungin and amphotericin B. However, strains demonstrating increasing antifungal resistance over time have been seen in outbreaks in other communities. See CDC's guidance for more detailed treatment information.

For additional information, visit https://www.cdc.gov/fungal/candida-auris/index.html .
Healthcare facilities or laboratories that suspect they have a patient C. auris colonization or infection should contact the Orange County Health Care Agency Epidemiology and Assessment Division immediately at 714-834-8180.
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