Candida auris Found in a U.S. Patient Evacuated from a Hospital in Kenya, Maryland, 2018

Candida auris is an emerging drug-resistant yeast that causes outbreaks in health care facilities. First identified in Japan in 2009, it has now been reported in about 30 countries. U.S. cases most likely began as importations from abroad, followed by extensive local spread in health care settings.

It spreads in hospitals because it is hard to identify, persists on surfaces and equipment, and is only partly killed by some standard hospital disinfectants. In the United States, outbreaks have occurred most often in high-acuity postacute care facilities, including nursing homes that care for patients on ventilators. It is regularly found together with other emerging multidrug-resistant organisms, including carbapenemase-producing organisms (CPOs) such as carbapenem-resistant Enterobacteriaceae (CRE) — organisms for which U.S. testing and public health response grew substantially from 2017.

CDC's visual summary of the report.

The patient

In September 2018, the Maryland Department of Health (MDH) learned of a patient just medically evacuated from Kenya to an acute care hospital in Maryland.

• A U.S. resident, not a health care worker, who had a cerebral hemorrhage while visiting Kenya.
• A month in a Kenyan hospital: several operations and other procedures, including arterial clipping and placement of a tracheostomy and a feeding tube; complicated by sepsis, pneumonia and a urinary tract infection, treated with broad-spectrum antibiotics and at least one course of antifungals.

In Maryland. Because the patient had received health care abroad, the hospital put them on contact precautions in a private room from the moment of admission. Cultures taken for continuing fevers grew several highly drug-resistant organisms:

Looking for C. auris

At the time, C. auris had been reported from one major hospital in Kenya — not the one where this patient stayed. But MDH had seen it before: C. auris colonization in a patient with several CPOs after a long hospital stay in India. Weighing the long hospitalization in a country with known cases, the patient's CPOs, and that experience, MDH and CDC advised the hospital to screen for C. auris.

• Hospital day 12: one skin swab of both axillae and the groin (one swab for all four areas) grew C. auris, identified by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry — colonization, with no signs or symptoms of infection.
• So the patient got no antifungal treatment in the United States, and was later discharged to a rehabilitation facility.
• 21 patients on the same unit were screened: all negative.

Why it matters

Spread was likely prevented by the hospital's quick recognition of the patient's high risk and immediate contact precautions. Where patients with C. auris were not identified at once and no special infection control was used, it has spread: in one long-term care ventilator unit, nearly half of patients were colonized within months of the first patient's arrival.

• Clinicians should suspect C. auris in anyone admitted after health care abroad — even where it is not known to be widespread.
• 11 other U.S. patients with C. auris had recently been hospitalized abroad — in India, Pakistan, South Africa, the United Arab Emirates and Venezuela. At least six of them also carried CPOs (possibly more, since not all were tested). Whole genome sequencing placed all 12 patients' isolates, this one included, in the same clades as isolates from the countries where they had received care.
• In critically ill patients, the two travel together: 50% of patients with C. auris are also colonized with a CPO.

What CDC recommends

• Screen for C. auris anyone who has had an overnight stay in a health care facility outside the United States in the past 12 months, especially in a country with documented C. auris.
• This adds to CDC's 2013 recommendation: patients with an overnight stay in a health care facility abroad in the past 6 months go on contact precautions and are screened for CPOs such as CRE.
• Facilities should reliably collect patients' histories of medical care abroad; patients should tell their providers about any care received abroad.
• A public health response is recommended to even single cases of unusual resistance, including most CPOs. Every CPO investigation should ask whether the patient had overnight health care in a country with C. auris, and patients not yet screened should be tested promptly.
• In such patients, yeast found in any clinical culture should be identified to the species level, whatever the body site.
• Free testing: C. auris confirmation, carbapenemase testing for Enterobacteriaceae, Pseudomonas aeruginosa and Acinetobacter baumannii, and colonization screening for CPOs and C. auris, through CDC's Antibiotic Resistance Laboratory Network.

Sources

Based on Brooks RB, Walters M, Forsberg K, Vaeth E, Woodworth K, Vallabhaneni S, "Candida auris in a U.S. Patient with Carbapenemase-Producing Organisms and Recent Hospitalization in Kenya," MMWR Morbidity and Mortality Weekly Report, volume 68, Centers for Disease Control and Prevention; a work of the United States government in the public domain.