‘It can be done’: Public health officials contain C. auris in California facilities

A multipronged intervention that consisted of a two-part surveillance program and rapid investigations led to a “swift identification and containment” of Candida auris in part of California, researchers wrote.

The intervention was implemented in all three long-term acute care hospitals (LTACHs) and 14 ventilator-capable skilled-nursing facilities (vSNFs) in Orange County, California, after enhanced laboratory surveillance detected C. auris in a patient from one of the facilities in February 2019, the researchers noted.

“When [C. auris] was first identified in the major population center of Southern California 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 within CDC’s Mycotic Diseases Branch, told Healio Primary Care.

Multipronged intervention

Surveillance was primarily conducted through point prevalence surveys (PPSs). According to the researchers, this consisted of collecting and testing axilla-groin and nasal screening swabs from all facility patients without known C. auris. Facilities that yielded more than one new C. auris screening case took axilla-groin screening swabs every 2 weeks to check for new cases. For secondary surveillance, patients who were discharged from one of the facilities with ongoing transmission were “placed on empiric transmission-based precautions with admission screening for C. auris by the receiving facility or provider,” the researchers wrote in Annals of Internal Medicine.

Ongoing facility-based transmission of C. auris was assumed if at least two sequential PPSs found new cases in patients who did not have known C. auris exposure at another facility, according to the researchers. Facilities with two negative PPSs within 1 month changed the screening frequency to one PPS per month. Those with no cases of C. auris during initial screenings performed another PPS 6 months later.

“The best chance at stopping [C. auris] was to do colonization testing at all of the LTACHs and vSNFs in the area,” Jackson said.

In addition to surveillance, infection prevention and control experts provided the facilities with oral and written feedback and recommendations regarding the appropriate use and locations of alcohol-based hand sanitizer. They conducted assessments of staff members’ hand hygiene, procedures for cleaning surfaces and shared medical equipment, as well as electronic health record processes for patients with known multidrug-resistant organisms. The infection prevention and control experts made several visits to facilities with two or more positive PPSs to gauge the facilities’ efforts to improve their procedures, according to the researchers.

Efficacy of the intervention

Jackson and colleagues reported that laboratory surveillance detected C. auris 3 months before routine methods identified the first bloodstream infection. The first round of PPSs resulted in 44 additional cases of C. auris being identified at nine facilities. By October 2019, 182 cases were identified through serial PPSs and discharge testing. Of 81 isolates that were sequenced, all were “highly related,” the researchers wrote. The C. auris outbreak was contained to two facilities by October 2019 and “sustained containment” was reported through December 2019.

Before the infection prevention and control assessments, the researchers noted that hand hygiene rates at the nine facilities with C. auris were less than 80%. Five facilities had hand hygiene rates of less than 65%. Seven of the facilities had alcohol-based hand sanitizer containers inside 70% or more of patient rooms and only two had containers outside 70% or more of patient rooms. Jackson and colleagues also said they found gaps in cleaning, staff responsibilities, proper signage and EHR use. Over time, “intensive support” from the infection prevention and control experts yielded “improved hand hygiene and qualitative improvement in environmental cleaning at several facilities,” the researchers wrote.

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

“Bottom-line: If you detect C. auris in a patient, think hard about where they might have been exposed,” Jackson said. “If you see one case, there are likely many others that are undetected. Don’t think just about your hospital or long‐term care facility, think about the local network of facilities. Report the case as soon as possible to public health. 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 Lona Mody, MD, MSc, both of the division of geriatric and palliative care medicine at the University of Michigan Medicine School, also noted that when C. auris occurs in a health system, the entire system must be part of the containment approach, not just the location where the initial infection was found.

They added that Jackson and colleagues “present a warning of the increasing threat of C. auris epidemics,” and the study “provides clear and reproducible strategies on how such battles may be fought and won.”

“Future research should involve, among other elements, efforts in deciphering the most common chains of C. auris transmission, as well as establish integrated and cost-effective surveillance networks that harmonize sensible active screening with improved knowledge of clinical risk factors,” Cassone and Mody wrote.

References:

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

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