1.
Michell Reyes, MT, CIC, FAPIC
Memorial Sloan Kettering Cancer Center
APIC Greater NY Chapter 13- Journal Club- 9/20/17

2. Candida auris
Is a species of ascomycetous fungus, of the Candida genus which grows as yeast.
First reported from Japan in It was isolated from the external ear canal from a patient.
Latin word for ear is auris.

3. Why is everyone concerned?
Current diagnostic methods used in the majority of the hospitals are inadequate for C. auris ID.
It has caused outbreaks in healthcare settings.
CDC is concerned about C. auris for three main reasons:
It is often multidrug-resistant, meaning that it is resistant to multiple antifungal drugs commonly used to treat Candida infections.
It is difficult to identify with standard laboratory methods, and it can be misidentified in labs without specific technology. Misidentification may lead to inappropriate management.
It has caused outbreaks in healthcare settings. For this reason, rapid identification of C. auris in a hospitalized patient is particularly important so that healthcare facilities can take special precautions to stop its spread.
Resistant to multiple antifungal drugs

4. A global map representing a rapid emergence of multidrug-resistant clinical Candida auris strains in 5 continents
93% resistance to fluconazole, 54% to voriconazole, 35% to amphotericin B, 7% to echinocandins, 6% to flycytosine.
41% resistant to >2 classes, 2 isolates resistant to 3 classes.
Chowdhary A, Sharma C, Meis JF (2017) Candida auris: A rapidly emerging cause of hospital-acquired multidrug-resistant fungal infections globally. PLOS Pathogens 13(5): e

5. August 2017 Webinar

6. Candida auris cases in the United States, as in July 31st 2017
Number of cases reported

7. Recommendations for Infection Control
Single room
Standard and Contact Precautions
Emphasizing adherence to hand hygiene.
Screening contacts of the patients to identify C. auris colonization.
Cleaning and Disinfecting the patient care environment. Both daily and terminal, using an EPA-registered hospital grade disinfectant effective against Clostridium difficile spores.
Infection Control
Placing the patient with C.  auris in:…………………….
C. auris can persist on surfaces in healthcare environments. Quaternary ammonia products that are routinely used for disinfection may not be effective against C. auris. For C. auris, CDC recommends use of an Environmental Protection Agency (EPA)-registered hospital-grade disinfectant effective against Clostridium difficile spores (List K). It is important to follow all manufacturers’ directions for use of the surface disinfectant, including applying the product for the correct contact time.
Thorough daily and terminal cleaning and disinfection of patients’ rooms and cleaning and disinfection of areas outside of their rooms where they receive care (e.g., radiology, physical therapy) is necessary. Shared equipment (e.g., ventilators, physical therapy equipment) should also be cleaned and disinfected before being used by another patient.

8. Monitoring Environmental cleaning and disinfection
Proper use of disinfectant (preparation, contact time, etc)
Objective evaluation of thoroughness;
Direct observations
Fluorescent markers
ATP bioluminescence.
In NY as 6/9/17:
Environmental Specimens Positive = 58
[Bed rail, window sill, mattress, carpet, phone, TV remote, feed tube, chair, door knob, sink, etc.]

9. Infection Control breach observations
Environmental Cleaning
Ventilators not cleaned with sporicidal agent (two tested positive after terminal cleaning).
Shared equipment such as mechanical lifts not cleaned with sporicidal agent.
Spray on, immediately wipe off.
Using inappropriate products (e.g. inadequate kill claims, not intended for healthcare environment)
In NY as 6/9/17:
Environmental Specimens Positive = 58
[Bed rail, window sill, mattress, carpet, phone, TV remote, feed tube, chair, door knob, sink, etc.]

10. Journal Review for APIC GNY
C. auris
5 strains
C. albicans
4 strains
10 disinfectants
C. glabrata
3 strains
MRSA
3 strains

11. Testing of disinfectant efficacy:
Was conducted according;
To the American Society for Testing and Materials (ASTM) Standard quantitative carrier disk test method (ASTME ).
And
Association of Official Agricultural Chemists (AOAC) official method for Germicidal Spray products.
Originally developed in 1961, the AOAC Germicidal Spray Test is a standard method for evaluating the efficacy of liquid disinfectants on hard, non-porous surfaces. It is one of the EPA-specified test methods for antimicrobial pesticide registration. This method is particularly appropriate for disinfectants which do not require dilution and are designed to be used with an aerosol or trigger spray.
The method is semi-quantitative, meaning that it relies on a series of qualitative observations (a test tube changing from clear to turbid as a result of microbial growth). The time-lapse photo below shows this process as it happens over the course of 48 hours.

12. Characteristics of the Disinfectants tested

13. Mean log reductions for each of the disinfectants against the 3 Candida species and MRSA
Mean log reductions for each of the disinfectants against the 3 Candida species and MRSA using the American Society for
Testing and Materials (ASTM) Standard Quantitative Carrier Disk Test Method (ASTM E ).7 Log reductions were calculated by
subtracting viable organisms recovered after exposure to the disinfectants versus deionized water controls. Vinegar, Purell Healthcare Surface
Disinfectant, and the 2 quaternary ammonium disinfectants were significantly less effective against the Candida species than against MRSA
(P ≤ .02). Error bars show standard error. MRSA, methicillin-resistant Staphylococcus aureus
Log Reduction was calculated subtracting viable organisms recover after disinfectant exposure VS deionized water controls.

14. Limitations Studies only 2 quaternary ammonium disinfectants.
Can not exclude the possibility that other quaternary ammonium compounds may have greater activity.
Did not assess the efficacy of the disinfectants on hospital surfaces.
Possible that quaternary ammonium compounds may exhibit greater efficacy on real-world surfaces if smaller numbers of Candida species are present.