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Update: Candida auris in Orange County
April 16, 2019
Patients colonized with Candida auris ( C. auris ) have been identified recently at multiple healthcare facilities in Orange County. Colonized patients have been identified in Kindred Hospital, Santa Ana. Subsequent point prevalence surveys conducted in skilled nursing facilities who provide ventilator care (vSNFs) and who frequently share patients with Kindred, Santa Ana have identified additional suspect or confirmed positive patients. Some vSNF patients who tested positive have a history of admission to Kindred, Santa Ana, others do not. These patients are the first identified C. auris cases in Southern California.

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

Updated Recommendations:

  • All healthcare facilities should perform admission screening for C. auris and institute empiric Standard and Contact Precautions for patients admitted from facilities where C. auris-colonized patients have been identified. Patients who have been previously screened at the facility with C. auris-colonized patients should still have admission screening performed at the accepting facility.

  • Admission screening for C. auris should include a composite swab of the axilla and groin as well as a swab of the nares. The CDC recommends inclusion of swabbing of the nares to optimize testing yield. 

  • Hospitals accepting patients from facilities where C. auris-colonized patients have been identified should contact OCHCA at 714-834-8180 to arrange for receipt of screening swabs and coordinate their transfer to a public health laboratory for testing.  Testing for C. auris colonization is available through the Centers for Disease Control and Prevention (CDC) Antibiotic Resistance Laboratory Network. Commercial testing for C. auris screening is not available at this time. C. auris colonization testing by culture generally takes 7-21 days to result.

  • Facility-to-facility communication is critical when transferring a patient who is suspected or confirmed to be colonized or infected with C. auris. Any accepting facility should be made aware of the patient’s status.

  • Hospitals that frequently share patients with Kindred Hospital, Santa Ana 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.  

  • Facilities that do not frequently share patients with Kindred Hospital, Santa Ana are not currently recommended to change their laboratory testing or surveillance practices.
Background:
C. auris is an emerging yeast that is multidrug resistant and has a propensity to spread in healthcare settings. Outbreaks have occurred in several states, primarily in the eastern half of the country. One case was identified in Northern California in 2018. 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 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 below) throughout the unit or facility where patients with C. auris are located.

Patients have remained 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.
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. See CDC's guidance for more detailed treatment information.
For additional information, visit https://www.cdc.gov/fungal/candida-auris/index.html
Contact Information:
Healthcare facilities or laboratories that suspect they have a patient with 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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