ICMR Issues C. auris Advisory

The alarmingly rapid rise of multidrug-resistant Candida auris cases globally has prompted American and European centers for disease control to issue clinical alerts in 2016. In India, C. auris infections have also been increasingly reported across various centers since 2011. To help arrest the spread of this difficult-to-manage infection, the Indian Council of Medical Research (ICMR) released an advisory for healthcare providers (HCPs) in India.

As the advisory points out, many factors contribute to the difficulties in combating C. auris. For instance, the yeast is commonly misidentified by automated systems, and not all diagnostic laboratories in the country can carry out definitive confirmation of the species. C. auris persists for a longer time in the environment, is thermotolerant and salt-tolerant, forms biofilms on polymeric surfaces and resists the activity of antifungal drugs such as azoles, polyenes and even echinocandins. Unsurprisingly, C. auris is associated with high mortality rates.

Identification and susceptibility testing

HCPs are encouraged to be vigilant for C. auris infections and colonization, particularly in patients with long ICU stays and previously exposed to antifungals. Methods to rapidly and accurately identify the fungus are detailed in the advisory as well. Reliable identification is based on either matrix-assisted laser desorption ionization-time of flight (MALDI-TOF) with an upgraded database or sequencing of the internal transcribed spacer (ITS) and D1/D2 regions of ribosomal DNA. The advisory also emphasizes the importance of adherence to infection control practices, along with ongoing public health surveillance and investigations. Antifungal susceptibility testing for C. auris is still quite challenging, as epidemiological cut off values (ECVs) or clinical breakpoints are still not defined, and variation has been noted by different methods of susceptibility testing.

Treatment

There is currently no consensus for treatment because of variation in susceptibility, but fluconazole should be avoided, as resistance patterns show >90% resistance to the drug. Echinocandins remain the first-line therapy for C. auris infection, but caspofungin has been shown inactive against C. auris biofilms.

Infection prevention and environmental control

Standard, as well as contact, precautions should be implemented while caring for patients with suspected or confirmed C. auris infection. These patients should be kept in isolated rooms or with other patients with the same infection. It may be useful to separate patients with diarrhea, as they may have a higher risk of transmitting the organism to other patients and of self-colonization at multiple sites. World Health Organization-recommended steps for hand hygiene should be followed strictly by staff and patient attendants before and after contact. Soap and water and alcohol hand sanitizers with or without chlorhexidine have been found equally effective in eradicating hand carriage of C. auris. Other recommendations include: having dedicated equipment for infectious patients; catheter and tracheostomy site care; and, if possible, if procedures on infected or colonized patients are needed, they should be scheduled last for the day. Environmental control measures were also included, such as disinfecting surfaces with hypochlorite, hydrogen peroxide, quaternary ammonium compounds, phenol and alcohols. All patient care equipment should be cleaned and disinfected daily, and single-use devices are preferred. Autoclaving or ethylene oxide/gas plasma sterilization is preferred over high-level disinfection of reusable items.

Colonization screening

The advisory lists suggested screening sites based on the predilection of Candida spp. to colonize the skin and mucosal surfaces:

• axilla;
• groin;
• oral mucosa;
• urine/urethral swab;
• perineal or low vaginal swab;
• sputum/endotracheal secretions;
• drain fluid (abdominal/pelvic/mediastinal);
• cannula entry sites; and
• wounds.

Procedure for decolonization of the skin is also detailed. Patients should be sponged with 2% chlorhexidine gluconate; oral decolonization can be done by using 0.2% chlorhexidine mouthwash or 1% chlorhexidine dental gel in patients on ventilator support.

Reporting of cases

HCPs should suspect C. auris in the following situations:

• If the patient is from an ICU or high-dependency area;
• If the patient has been transferred from another hospital after a long stay;
• Multiple intervention and prior antifungal exposure in any patient;
• If the organism is identified in a commercial system as Candida haemulonii, famata, C. guilliermondii, C. lusitaniae, C. parapsilosis, Rhodotorula glutinis, Candida sake or Saccharomyces cerevisiae; and
• If the Candida appears to be resistant to fluconazole and with a high minimum inhibitory concentration (MIC) to voriconazole.

The ICMR urges HCPs to notify them of suspected or confirmed cases of C. auris infection or colonization. The suspected C. auris isolates can be sent to laboratories at the Postgraduate Institute of Medical Education and Research, Chandigarh, and/or the Vallabhbhai Patel Chest Institute at the University of Delhi for identification and characterization.

Other contact details and the full advisory can be downloaded here.