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May 10, 2019

What hospitals need to know about the deadly C. auris outbreak

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    In recent years, hospitals in the United States and abroad have been grappling with a little-known drug-resistant fungus called Candida auris (C. auris)—and some experts say its silent spread raises questions about CDC's hospital reporting policies for such outbreaks.

    From outbreaks to hurricanes: How can hospitals prepare for disasters?

    What we know about C. auris

    C. auris is a fungus that can cause deadly bloodstream, middle ear, and wound infections. According to the New York Times, CDC estimates more than 90% of C. auris infections are resistant to at last one antifungal drug, while 30% are resistant to at least two major drugs.

    The infections typically are not dangerous for young, healthy individuals, but they can be fatal for high-risk patients, such as those who have diabetes, were recently on antibiotics, or recently had surgery. According to CDC, nearly half of patients who contract C. auris die within 90 days.

    In recent years, C. auris cases have spread in the United States and abroad, the Times reports. The earliest known case of C. auris in the United States occurred in May 2013, but since then, there have been 587 more U.S. cases, concentrated in New York, New Jersey, and Illinois, according to CDC data.

    The symptoms—aches, fever, and fatigue—make it difficult to diagnose, and experts have found that C. auris can be even harder to treat and scrub from facilities. According to the Times, Mount Sinai in New York City had to bring in special cleaning equipment and remove some ceiling and floor tiles after a patient was diagnosed with the infection.

    Lynn Sosa, Connecticut's deputy state epidemiologist, told the Times she now views C. auris as "the top" threat among antibiotic-resistant infections. "It's pretty much unbeatable and difficult to identify," she said.

    Outbreak prompts debate around reporting policies

    According to the Times, CDC in June 2016 alerted U.S. hospitals to a C. auris outbreak at a London hospital and instructed hospitals to contact the agency if they noticed similar symptoms or had questions. Snigdha Vallabhaneni, a member of CDC's fungal team, said the agency expected to receive "maybe a message every month." Instead, the queries came rushing in, including one case dating as far back as 2013 in which a woman who tested positive for the fungus died in a New York City hospital.

    But while public health officials and hospitals have been alerted to the fungus and the danger it poses, little of this information has been released to the general public. According to the Times, CDC policy gives states the primary role in deciding whether to publicly report hospital-based outbreaks, and often states decline to release that information.

    Critics say the current policy makes it difficult to track and identify existing outbreaks, and prevents patients from knowing whether they are being treated at a hospital where they risk exposure to the fungus.

    But public health and hospital officials say that releasing such information could lead to a public panic and cause patients to avoid seeking care at affected facilities, even though Slate's Susan Matthews notes the risk of becoming infected with the fungus is very low.

    Jason Burnham, an infectious disease specialist at Washington University School of Medicine, said, "If people are too scared to go to the hospital, they may delay their care, becoming sicker and sicker until their situation is an emergency."

    According to Burnham, another factor is that current guidelines do not clearly state when it is necessary to report cases. He said, "Should a single case mandate public reporting? At one case, it's possible that no other patients would be affected. So do you wait for two? Or three? If you report too soon and it turns out not to be an outbreak, then the public gets scared for nothing."

    A CDC spokesperson said hospitals also are at risk of being blamed for an outbreak they did not start. The spokesperson noted, "Patients move between facilities while receiving care and may have picked up a superbug from another facility or from the community."

    Many remaining unknowns

    Further, when it comes to C. auris, there are many unknowns, the Times reports. For instance, public health experts still do not know how the fungus spreads, its origins, or how to stop it.

    Jacques Meis, a microbiologist in Nijmegen, the Netherlands, who has studied the drug-resistant fungus, said he believes it originates in soil and stems from the increased use of azole pesticides in crops.

    Tom Chiller, who leads CDC's fungal branch, similarly speculated that C. auris has existed for thousands of years but became more prominent and drug-resistant due to the increased use of azoles.

    Johanna Rhodes, an infectious disease expert at Imperial College London who worked on the London hospital outbreak, said, "We are driving this with the use of antifungicides on crops." She added that azoles are being sprayed "[o]n everything—potatoes, beans, wheat, anything you can think of, tomatoes, onions."

    How hospitals, nursing homes are preventing the spread of C. auris

    Without clear guidelines on how to effectively treat and eliminate C. auris, hospitals in the United States and abroad are testing various approaches. 

    For example, hospitals and nursing homes in California and New Jersey are testing whether a special soap, called chlorhexidine, can combat C. auris.

    Susan Huang, who specializes in infectious diseases at the University of California-Irvine and is leading one of the projects to test the soap's effectiveness, said preliminary data show it appears to be working.

    Researchers after 18 months have seen a:

    From outbreaks to hurricanes: How can hospitals prepare for disasters?

    Hospitals must be prepared for myriad disasters that can stress health care systems to the breaking point and disrupt delivery of vital health care services.

    Advisory Board has compiled step-by-step procedures for various threats your facility may encounter—though we hope you'll never need to use them.

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