Infectious Disease

Public health officials included C. auris in California facilities


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A multi-pronged intervention that consisted of a two-part surveillance program and rapid investigations resulted in “rapid identification and containment” of Candida auris in part of California, the researchers wrote.

The intervention was carried out in all three long-term acute care hospitals (LTACHs) and 14 ventilated qualified care facilities (vSNFs) in Orange County, California after increased laboratory monitoring found C. auris in a patient from one of the facilities in February 2019, the researchers revealed fixed.

“When [C. auris] was first identified in Southern California’s main population center in early 2019, we in public health knew we had to act quickly to slow or stop its spread. Brendan R. Jackson, MD, an epidemiologist in the CDC’s Mycotic Diseases Division told Healio Primary Care.

Multi-pronged intervention

The monitoring was mainly carried out through point prevalence surveys (PPS). According to the researchers, this consisted of collecting and testing axillary inguinal and nasal screening swabs from all patients at the facility with no known C. auris. Facilities that returned more than one new C. auris screening case took axillary inguinal screening smears every 2 weeks to check for new cases. For secondary monitoring, patients discharged from any of the sustained transmission facilities were “placed on empirical transmission precautions with admission screening for C. auris by the receiving facility or provider,” the researchers wrote in Annals of Internal Medicine.

Sustained facility-based transmission of C. auris was presumed when at least two consecutive PPSs found new cases in patients who had no known C. auris exposure in another facility, the researchers said. Facilities with two negative PPS within one month changed the screening frequency to one PPS per month. Those who had no cases of C. auris during the initial screenings did another PPS 6 months later.

“The best chance to quit [C. auris] was to run colonization tests on all LTACHs and vSNFs in the area, ”Jackson said.

In addition to monitoring, infection prevention and control experts provided verbal and written feedback and recommendations to facilities on the appropriate use and location of alcohol-based hand sanitisers. They conducted employee hand hygiene assessments, procedures for cleaning surfaces and shared medical devices, and electronic health record procedures for patients with known multi-drug resistant pathogens. The infection prevention and control experts visited facilities with two or more positive PPS multiple times to assess the facilities’ efforts to improve their procedures, the researchers said.

Effectiveness of the intervention

Jackson and colleagues reported that laboratory monitoring detected C. auris 3 months before routine methods of identifying the first bloodstream infection. In the first round of PPS, 44 additional cases of C. auris were identified in nine facilities. As of October 2019, 182 cases had been identified through serial PPSs and discharge tests. Of 81 isolates sequenced, all were “highly related,” the researchers wrote. The C. auris outbreak was contained in two facilities by October 2019 and a “sustainable containment” was reported by December 2019.

Before performing infection prevention and control assessments, researchers found that the hand hygiene rate in the nine facilities with C. auris was below 80%. Five facilities had a hand hygiene rate of less than 65%. Seven of the facilities had containers for alcohol-based hand sanitizer in 70% or more of the patient rooms and only two had containers outside of 70% or more of the patient rooms. Jackson and colleagues also said they found gaps in cleaning, staff responsibilities, proper signage, and EPA use. The “intensive support” from the experts in infection prevention and control has led over time to “improved hand hygiene and the qualitative improvement in environmental cleaning at several facilities,” the researchers write.

Although public health officials managed to contain the C. auris outbreak in 2019, Jackson said the COVID-19 pandemic “has undone containment efforts in the area”. Still, the study has important implications.

“Bottom line, if you discover C. auris in a patient, think carefully about where they might be exposed,” said Jackson. “If you see one case, there are likely many others that go undetected. Think not only of your hospital or long-term care facility, but also of the local network of facilities. Report the case to public health as soon as possible. Under the right circumstances, we can contain the spread of C. auris. It is not easy, but it can be done. “

‘Clear and reproducible strategies’

In a related editorial Marco Cassone, MD, and Canvas Modifications, MD, MSc, both from The Department of Geriatrics and Palliative Care at the University of Michigan Medicine School also noted that if C. auris appears in a healthcare system, the entire system must be part of the containment approach, not just where the initial infection was found.

They added that Jackson and colleagues “provide a warning of the increasing threat posed by C. auris epidemics” and that the study provides “clear and reproducible strategies for how such battles can be fought and won”.

“Future research should include efforts to decipher the most common C. auris transmission chains and establish integrated and cost-effective surveillance networks that balance meaningful active screening with improved knowledge of clinical risk factors,” wrote Cassone and Mody.


Cassone M. et al. Anna Intern Med. 2021; doi: 10.7326 / M21-3456.

Karmarkar EN, et al. Anna Intern Med. 2021; doi: 10.7326 / M21-2013.


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