The CDC and Public Health England (PHE) have both recently updated their guidelines for detecting and managing cases of infection with Candida auris. C. auris is an emerging multidrug-resistant yeast that causes candidaemia. Countries hard hit by C. auris include India, Pakistan, Venezuela, South Africa and Spain. There have been around 150 cases of infection and 150 of colonisation so far in the US, primarily in New York and New Jersey. Over 200 patients have been infected or colonised across the UK, although there have been no fatalities and the three worst-affected UK hospitals have now declared their outbreaks over.
Most isolates were resistant to at least one antifungal drug (most commonly fluconazole, but also amphotericin B and echinocandins).
It is also difficult to eliminate: patients can remain colonized for more than a year, and those in close contact to them may be colonized without showing symptoms. It can persist in the healthcare environment for weeks and is not killed by ammonium-based disinfectants.
The CDC currently recommends the following precautions:
- Determine the species of all Candida strains isolated from sterile sites (e.g. blood, CSF).
- Consider determining the species of Candida strains isolated from non-sterile sites (e.g. urine, wounds, sputum), particularly when the patient has recently had an overnight stay in a hospital in India, Pakistan, South Africa or Venezuela.
- Screen people who have been in close contact with the patient for colonization.
- Monitor patients closely for treatment failures (i.e. positive clinical cultures beyond 5 days).
- Clean affected wards and rooms with a disinfectant suitable for Clostridium difficile spores (a list of brands is available here).
Please visit the CDC website to read the clinical alert in full or for general information about C. auris.
PHE have published separate sets of guidance for healthcare settings, community care settings, and patients/visitors.
First case of echinocandin-resistant Candida albicans in Korea
A team of researchers from South Korea have identified a case of echinocandin-resistant Candida albicans. They describe the case of the multidrug resistant strain in an article published in the journal Annals of Laboratory Medicine.
The authors note that echinocandin resistance in Candida globally is within the range of 0–2.8%, and that echinocandin resistance in Candida albicans specifically is rare. The strain of C. albicans described in the article is resistant to the echinocandin drugs micafungin and caspofungin, as well as fluconazole and voriconazole. The strain was isolated from the blood of a patient with acute lymphoblastic leukaemia.
The article highlights the fact that immunocompromised patients may be at an increased risk of infection with antifungal-resistant strains, particularly if antifungals are used as part of prophylactic treatment. The authors note that resistance to echinocandins can result in failure to treat candidiasis, leading to increased likelihood of morbidity and mortality.
Coccidioidomycosis (Valley fever) missed as a cause of death in the USA
About 150,000 annual cases of coccidioidomycosis occur each year in the USA (especially in Arizona), and at least as many in Central and South America, of which about ~40% are symptomatic and clinically apparent. In Arizona, there was a 4-fold rise in the incidence of clinical cases between 1997 and 2013, to 90/100,000, yet attributable deaths remained unchanged. Using the capture/recapture approach, Jefferson Jones and colleagues found gross underestimates of coccidioidomycosis deaths in Arizona.
Between 2008-2013, both death certificates and hospital discharge data were analysed for deaths linked to or attributable to coccidioidomycosis. They estimated 1,178 coccidioidomycosis-attributable deaths during 2008–2013 in Arizona, compared with the reported number of 164 attributable deaths and 497 deaths including coccidioidomycosis.
Risks for death were increased for Hispanics (OR 1.3), those under 25 years old (OR 2.5), female, (OR 1.3), HIV-positive (OR 2.4) and disseminated and/or meningitis (OR 1.7). Being Native American or Black, over 85 years old and having chronic disease were at lower risk.
1 in 9 patients lose an eyeball to fungal eye infections in Pakistan
126 (11%) of the 1,130 patients with fungal keratitis (keratomycoses) lost their eyeballs according to a prospective 11 year study by Shah and colleagues in Pakistan. Over 50% of the remainder effectively lost their sight.
The study evaluated post-treatment visual outcomes of fungal keratitis. Treatment included antifungal preparations and symptomatic measures. Improvement in visual acuity was seen in 37% (416) of patients; 590 (52%) of patients retained visual acuity of not more than counting fingers, and evisceration of the orbit was done in 126 (11%). Patients with residual corneal opacity needed keratoplasty - the visual outcomes of these patients are not described.
Fungal keratitis is a major cause of infectious keratitis, usually following direct (often traumatic) implantation of fungus into the cornea, infected contact lenses, or excessive ocular steroid use. It is associated with poorer outcomes compared to bacterial or viral keratitis. Patients with fungal keratitis are at a greater risk of endophthalmitis and subsequent visual loss. Delayed treatment is complicated by complete corneal necrosis and perforation. The global burden of fungal keratitis is estimated at 1 million cases annually.