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October - 2018


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A Candida auris Outbreak and Its Control in an Intensive Care Setting

D.W. Eyre, A.E. Sheppard, H. Madder, et al New Eng J Med, 2018, 379:1322-31


Candida auris is an emerging, multi-drug-resistant pathogen that has recently been associated with outbreaks worldwide, often in intensive care units (ICUs)”. This NEJM article describes an outbreak of C.auris in the neuro-ICU in Oxford, and the identification and intervention program.

It was first identified in 2009, with subsequent reidentification of over 15000 invasive candida isolates from international invasive samples collected from 2004 onward identifying 4 isolates, and supports the emergence of C. auris. The introduction discusses the difficult to explain scenario of a relatively old species causing simultaneous, newly recognized disease among patients worldwide. The theories include changes in the natural environmental, changing antifungal prophylaxis and treatment, changing approaches to diagnosis and to the identification of species, or changes in health care environments.

After an outbreak in 72 patients in a cardiothoracic ICU near London in 2015, the Oxford NHS Trust performed a look back exercise and identified 9 patients colonised or infected with C.auris, 8 of whom had been in the neuro-ICU. As a result routine screening for C.auris began in October 2016. This included 3x week sampling from the ICU and neighbouring neuro-ward, and whole genome sequencing. 

They found;

  • Cases: Were identified as not having C.auris prior to ICU admission. 70 patients were identified as colonised or infected with C.auris between Feb 2015 and Aug 17, with median ICU LOS 8 days prior to positive culture. Invasive infection occurred in 7. 1 patient with c.auris died, although this occurred over 200 days after last isolate, so there were no deaths attributable to C.auris. In terms of screening, 900 patients had 2780 patient-days, and 62 patients returned positive swabs. Acquisiton rate was 2.9 cases per 100 neuro-ICU days
  • Controls: Patients who had never been colonized or infected with C. auris and admitted to neuro-ICU before they had one or more negative screens.
  • After multivariate analysis, risk of infection;
    • initially increased with ICU LOS, before declining with longer stay (P=0.001)
    • risk of colonization was greatest in association with high-normal to moderately elevated neutrophil counts (P=0.01)
    • risk of colonization or infection associated with any skin-surface axillary temperature monitoring with the use of reusable probes (OR 6.80; 95% CI, 2.96 to 15.63; P<0.001). These temperature probes were used in 57 case patients (86%) and 122 controls (34%). 
    • Systemic fluconazole treatment associated with increased risk (OR 10.3; 95% CI, 1.64 to 65.2; P=0.01), although only 3 case patients (5%) received antifungal agents before colonization or infection.
  • Environmental screen and infection control response: C.auris was rarely detected in general environment or air, but was deleted form reusable patient-monitoring equipment (axillary temp probes and pulse oximeter)
  • Antifungal susceptibility testing:  100% resistant fluconazole, 98% resistant to voriconazole, 90% resistant to posiconazole. 18% were amphotericin resistant, none were micafungin or flu cytosine resistance. 
  • Survival and carriage duration: There was no association between case vs control and 30-d mortality. Isolation occurred initially in axillary sites most frequently.The median duration of carriage amongst patients who remained alive was 61-days. 

In summary, this paper describes the outbreak of C.auris in a neuroscience ICU. The source appears to be attributed to persistence on reusable equipment, particularly skin-surface probes. C.auris is resistant to fluconazole, voriconazole, posiconazole, with 18% resistance to amphotericin. Although persistent, invasive infections were uncommon, and there were no deaths attributed to this fungus.




Candida auris is an emerging and multidrug-resistant pathogen. Here we report the epidemiology of a hospital outbreak of C. auris colonization and infection.


After identification of a cluster of C. auris infections in the neurosciences intensive care unit (ICU) of the Oxford University Hospitals, United Kingdom, we instituted an intensive patient and environmental screening program and package of interven- tions. Multivariable logistic regression was used to identify predictors of C. auris colo- nization and infection. Isolates from patients and from the environment were ana- lyzed by whole-genome sequencing.


A total of 70 patients were identified as being colonized or infected with C. auris between February 2, 2015, and August 31, 2017; of these patients, 66 (94%) had been admitted to the neurosciences ICU before diagnosis. Invasive C. auris infections de- veloped in 7 patients. When length of stay in the neurosciences ICU and patient vital signs and laboratory results were controlled for, the predictors of C. auris colo- nization or infection included the use of reusable skin-surface axillary temperature probes (multivariable odds ratio, 6.80; 95% confidence interval [CI], 2.96 to 15.63; P<0.001) and systemic fluconazole exposure (multivariable odds ratio, 10.34; 95% CI, 1.64 to 65.18; P=0.01). C.auris was rarely detected in the general environment. How- ever, it was detected in isolates from reusable equipment, including multiple axillary skin-surface temperature probes. Despite a bundle of infection-control interventions, the incidence of new cases was reduced only after removal of the temperature probes. All outbreak sequences formed a single genetic cluster within the C. auris South Af- rican clade. The sequenced isolates from reusable equipment were genetically related to isolates from the patients.


The transmission of C. auris in this hospital outbreak was found to be linked to reusable axillary temperature probes, indicating that this emerging pathogen can persist in the environment and be transmitted in health care settings.


Previous Comments

Any data on incidence of C. auris in MICU
Shweta-11 Oct, 2018 03:15:09 AM

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