National Center for Emerging and Zoonotic Infectious Diseases

Candida auris: is it here to stay?

Shawn R. Lockhart, Ph.D., D(ABMM), F(AAM)Senior Clinical Laboratory Advisor

Senior Advisor for AMRCDC Mycotic Diseases Branch

Association of Public Health LaboratoriesSeptember 18, 2019

CBS News

Objective Points

• Candida auris is here

• Candida auris is deadly

• Candida auris can be slowed

What do we know about Candida?

Candida speciesThey are gut bugs

Mostly antifungal susceptible

Rarely causes outbreaks

Candida aurisIt is a skin bug

Mostly antifungal resistant

Frequently causes outbreaks

C. auris in 2009

C. auris in 2015

C. auris in 2019

CDC issued a clinical alert to healthcare facilities – June 2016

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C. auris clinical cases reported — United States, June 2016

CDC’s clinical alert

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New York New Jersey Maryland Illinois

C. auris clinical cases reported by state — United States, 2013–December 2016

CDC issued a clinical alert on C.

auris

05

101520253035404550

New York Illinois New Jersey FloridaMassachusetts California Maryland TexasIndiana Oklahoma Connecticut Virginia

C. auris clinical cases reported by state — United States, 2013–July 2019

~800 clinical cases~2350 clinical + screening cases

Number of C. auris clinical cases

012-1011-5051-100101 or more

Clinical cases of C. auris reported in the United States as of July 31, 2019

~800 cases1550 colonized

WGS relationships among C. auris isolates

East Asia

Africa

South Asia

South America

B11209 India 2013

SRR1664627 India 2013

B11218 India 2014

B11217 India 2014

B11216 India 2014

B11215 India 2014

B11214 India 2014

B11213 India 2014

B11212 India 2014

B11210 India 2013

B11096 Pakistan 2014

B11101 Pakistan 2014

B11118 Pakistan 2015

B11113 Pakistan 2015

B11114 Pakistan 2015

B11097 Pakistan 2014

B11117 Pakistan 2015

B11104 Pakistan 2015

B11105 Pakistan 2015

B11098 Pakistan 2014

B11116 Pakistan 2015

B11115 Pakistan 2015

B11103 Pakistan 2015

B11099 Pakistan 2014

B11200 India 2012

ERR899743 India

B11205 India 2013

B11201 India 2012

B11207 India 2013

B11208 India 2013

B11206 India 2013

B11112 Pakistan

B8441 Pakistan 2010

B11230 South Africa 2014

B11224 South Africa 2013

B11228 South Africa 2014

B11226 South Africa 2014

B11221 South Africa

B11222 South Africa 2012

B11223 South Africa 2013

B11225 South Africa 2014

B11227 South Africa 2014

B11229 South Africa 2014

B11220 Japan 2009

B11247 Venezuela 2012

B11244 Venezuela 2012

B11245 Venezuela 2012

B11243 Venezuela 2013

B11246 Venezuela 2012

110

19688

250

265

11226

11975

8110

27366

47473

• Very different across regions

• Nearly identical within regions

East Asia

South Asia

Africa

South America

Known introductions in the US

B17654 FL B17054 FL

B17018 FL B17656 FL

B17655 FL B16417 Kenya

B16517 Kenya B16491 Kenya

B17653 FL B17050 FL

Florida isolates

B16482 Kenya B16462 Kenya

B16500 Kenya B16454 Kenya

B16485 Kenya B11227 South Africa

B11229 South Africa B16489 Kenya

B12631 IN001 B11225 South Africa

3001643608 TX002Indiana, Texas isolates

B16515 Kenya B16328 MD

Maryland Isolate

3001643611 CA 3001643609 CA 3001643610 CA 3001643642 CA002 3001641578 CA002 Clinical 3001643643 CA

California isolates

B16425 Kenya B16518 Kenya B16501 Kenya

B16445 Kenya B16457 Kenya

B16410 Kenya B16480 Kenya

B11224 South Africa B11226 South Africa

B16407 Kenya B11223 South Africa B11221 South Africa

B11222 South Africa B16452 Kenya

B11230 South Africa

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WGS proof of independent introduction of the same clade across several states

Molecular epidemiology: are there more clades?

>1000 isolates22 countries

Clade I South-East Asia

Clade IIIAfrica

Clade IIEast Asia

Clade IV South America

USPakistanIndiaSouth AfricaSouth KoreaVenezuelaJapanCanadaIsraelColombiaIran

3001716699

B12555

B12531

B12549

B11810 MD001

B13519

B13520

B11861 NY001

B12045 NY001

B11116 Pakistan

B12079

B12089

B12428

B11201 India

B13696 CA001

3001721428 GA

B14068 MD

B11096 Pakistan

B11209 India

B11214 India

B11112 Pakistan

B8441 Pakistan(Reference)

B8441 Pakistan

B12037 Canada

B11230 South Africa

B11221 South Africa

3001644584

3001716286

3001644586

3001644585

3001643608 TX002

B11225 South Africa

B12631 IN001

3001716708

B17654 FL

B17915

B16328 MD

B17834

B17833

3001717113 LongBeach

B17743

B17835

B17741

B17742

B17721 CA002

B17746

B12043 NY003

B11220 Japan

B11808 South Korea

B11809 South Korea

B11245 Venezuela

B11247 Venezuela

B11244 Venezuela

B11894 Israel

B11895 Israel

B11896 Israel

3000912664 Coata Rica

3001716760 CostaRica traveler

B11778 Colombia

B11846 Colombia

B11851 Colombia

B14303 OK002

3001620899

3001721417 IN

B11842 IL002

3001620892

3001620893

3001620900

3015352932

3015352934

B11843 IL001

B12493 MA001

NG-19339 Iran

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WGS results for Indiana, Costa Rica isolates

South America Clade

B11247

B11245

B11244Venezuela

B11895

B11894

B11896Israel

3001716760 CA (Costa Rica traveler)

3000912664 Costa Rica

B11846

B11778

B11851Colombia

B14303 OK002

3001721417 IN

3001620899

B11842 IL002

3001620893

3001620892

3001620900

3015352932

3015352934

B12493 MA001

B11843 IL001

US

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South Africa 14% of candidemia in surveillance in South Africa was due to C. auris

Van Schalkwyk (2019) EID 25:1698

C. auris can overwhelm a healthcare system

• C. auris cases are additive, increasing overall candidemia rate• Published crude mortality ranges from 25% to >60%

https://www.eccmidlive.org/#resources/how-should-we-manage-the-c-auris-outbreak

Targets the most vulnerable

Multiple healthcare stays (acute and long term)

Multiple underlying conditions, indwelling devices– Tracheostomy– Ventilator – Peg tube– Central lines– On antibiotics and antifungals

C. auris persists in the healthcare environment

Mobile equipment has been heavily implicated in transmission

Hotbed of C. auris activity

• LTACH• Long-term Acute Care Hospital

• vSNF• Ventilator Skilled Nursing Facility

Stays in certain types of post-acute care facilities is a major risk factor: vSNFs and LTACHs

0.7%

C. auris prevalence in regular nursing homes

C. auris prevalence in nursing home units with ventilator beds

7.7% Adams EH, Quinn M, Ostrowsky B, et al. The Value Added from Candida auris Point Prevalence and Environmental Studies in New York State. 2018. Available at: https://idsa.confex.com/idsa/2018/webprogram/Paper72423.html.

• Colonization means patients are:• at risk for developing invasive

infection • A source of transmission to

others• Almost 100 cases of BSI in colonized

patients who were being followed 2016-2018

C. auris colonization can precede infection

Slide courtesy of Chicago Department of Public Health.

vSNF colonization March 2017

Slide courtesy of Chicago Department of Public Health.

vSNF colonization January 2018

Slide courtesy of Chicago Department of Public Health.

vSNF colonization January 2018

C. auris colonization often associated with CRE carriage

Proactive Public Health responseCalifornia• Performing proactive urine culture identification• Discovered a case in an LTACH, performed

extensive point prevalence surveys of LTACHS and vSNFs

• Identified >100 colonized patients

• Implemented extensive infection control

• Has kept case count below 5

?What don’t we know?

Laboratory updates

Laboratory Safety• Lab coat and gloves, and eye protection if spatter or splash may occur

• Use a biological safety cabinet (BSL2) or glove box when manipulating known or suspected C. auris isolates.

• To disinfect surfaces contaminated with C. auris, use 10% bleach (made fresh daily) or other bleach-based products. Alternatively, disinfectants on the USA Environmental Protection Agency List K

• After work with C. auris is complete, decontaminate the biological safety cabinet with 10% bleach

https://www.cdc.gov/fungal/candida-auris/c-auris-lab-safety.html

Update on lab methods for detecting C. auris• FDA approvals

• VITEK MS MALDI-TOF• Bruker Biotyper MALDI-TOF• GenMark ePlex BCID-FP panel blood culture test

• Other available tests• VITEK 2 8.01 update• PCR• Bruker FungiPlex

https://www.cdc.gov/fungal/candida -auris/recommendations.html

VITEK 2 update 8.01J Clin Microbiol. 2019 Aug 14. pii: JCM.00884-19. doi: 10.1128/JCM.00884-19. [Epub ahead of print]Identification of Candida auris using the updated 8.01 VITEK®2 yeast identification system: a multi-laboratory evaluation study.Ambaraghassi G1,2, Dufresne PJ3, Dufresne SF1,2,4, Vallières É2,5,6, Muñoz JF7, Cuomo CA7, Berkow EL8, Lockhart SR8, Luong ML9,2.

• Still difficulties distinguishing between C. auris and C. duobushaemuloniiespecially for isolates from East Asia and Africa• South Asia – 74%• East Asia – 0%• Africa – 7%• South America – 100%

Resistance: C. glabrata

7/1700 resistant to fluconazole and micafungin

8%Azoles

3%Micafungin

Global C. auris antifungal resistance

0 10 20 30 40 50 60 70 80

Fluconazole

Amphotericin B

Echinocandins

% ResistanceN=912

US Resistance: C. auris

33% multidrug-resistant

1 2 3

88% 34% 3%Azoles EchinocandinsPolyenes

Pan-resistance

First 2 confirmed pan-resistant C. auris cases found in NY Identified by ARLN NE regional lab (Wadsworth/NY) Cases were unrelated Acquired resistance on treatment No transmission of resistance seen Pan-resistance has also been reported from a few other

countries

Nationally notifiable

• C. auris nationally notifiable as of 2019• In pilot testing phase for message mapping guide• Contact your local or state PHL for information on

reporting

Surveillance possibilities

Colonization screening Current recommendations are for a single swab of axilla x 2

and groin x 2– Some data that suggests also screening the nares can be

advantageous

Screening can be accomplished through culture of the swab in Sab salt dulcitol broth

PCR

https://www.cdc.gov/fungal/candida -auris/recommendations.html

Screening: Consider screening - Close healthcare contacts of patients with newly identified C. auris

infection or colonization

Patients who have had an overnight stay in a healthcare facility outside the United States in the previous one year, especially if in a country with documented C. auris cases.– Strongly consider screening patients colonized with carbapenemase-

producing Gram-negative bacteria. C. auris co-colonization with these organisms has been observed regularly.

https://www.cdc.gov/fungal/candida -auris/c-auris-screening.html

Identifying the species of Candida from urine and other non-sterile body sites Yeast from urine usually tossed out because not

considered an infection

~50%

Only about 50% of clinical C. auriscases are from blood

Periodic point prevalence surveys in LTACHs and vSNFs One state is conducting periodic PPS at LTACHs bordering a

high prevalence state Detected 4 cases of C. auris colonization within first few

rounds of screening

If you identify a C. auris, please notify your PHL and/or regional ARLN lab

More information can be found:

https://www.cdc.gov/fungal/candida-auris/

https://www.cdc.gov/drugresistance/solutions-initiative/ar-lab-network.html

For more information, contact CDC1-800-CDC-INFO (232-4636)TTY: 1-888-232-6348 www.cdc.gov

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Contact us at: candidaauris@cdc.gov

Thank you! Questions?