First outbreak of C. auris infections in South America
September 22 2016
C. auris has been increasingly reported in tertiary care hospitals, principally from India, Kuwait and South Africa. Now, 6 years after the first identifications in Asia, the first outbreak of C. auris in South America has been reported. Bloodstream isolates of C. auris were obtained from 18 critically ill patients admitted to a medical centre in Maracaibo, Venezuela centre over a 16 month period.. 13 paediatric patients (8 of whom were preterm neonates) and 5 adult patients were included and each had been admitted to the intensive care unit, exposed to antibiotics and multiple invasive medical procedures before developing fungemia.
Isolates were initially collected and processed by the BacT/ALERT 3D system. Species identification was carried out by the Vitek 2C yeast panel and isolates were initially mis-identified as C. haemulonii. (Note: C. auris phenotypically resembles Candida haemulonii . Commercially available biochemical-based tests, including API strips and VITEK-2, used in many U.S. laboratories to identify fungi, cannot differentiate C. auris from related species.)
Further investigation was carried out using molecular characterisation by internal transcribed tracer (ITS) rDNA sequencing and the isolates were identified as C. auris. The outbreak was confirmed by amplified fragment length polymorphism fingerprinting (AFLP). This analysis demonstrated that the isolates clustered close together, suggesting a clonal outbreak. The isolates were found to be resistant to azoles but susceptible to anidulafungin through antifungal susceptibility testing using the CLSI M27-A3/S4 broth microdilution method.
A multi-disciplinary quality improvement intervention was implemented in order to control the outbreak. This included a central line insertion care bundle, consisting of hand hygiene, maximal sterile barriers and use of chlorhexidine for skin disinfection. Clinical management procedures included catheter removal and prompt antifungal therapy with different regimes. This resulted in a 72% survival at 30 days follow up. This is a higher rate than that reported from other outbreaks, which could be due to the large proportion of paediatric patients and the prompt removal of central venous catheters.
The mean time from hospital admission to the onset of candidemia was 24 days, comparable to other reports which range from 10-51 days. The delayed occurrence clearly suggests nosocomial acquisition and spread. C. auris is a multi-resistant yeast pathogen that can be a source of serious health-care associated infection in tertiary care hospitals. Despite efforts to control the outbreak, C. auris still ranks as a top 10 pathogen from blood-stream infections in the Venezuelan centre.
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