C. auris is so dangerous and easily spread that it is putting new kinds of pressures on the health care system according to The New York Times. It is observed that C. auris can be very difficult to clean from equipment or clothing, and it may spread through the air. Rashmi Karanjekar speaks to Dr. Prashant Nasa, Specialist and Head Critical Care Medicine; Chairperson, Prevention and Control of Infection Department, NMC Specialty Hospital, Al Nahda 2, Dubai to find out the impact on the Middle East region and the best practices to avoid the spread of this hostile fungus. Dr. Nasa has authored more than 25 publications in International Indexed journals. He is an active member of various International societies and reviewer with 10 international journal in field of critical care medicine.
Health experts issued a warning regarding a fungus called C. auris, which has been quietly spreading around the world. Can you please explain the impact of this fungus in the healthcare facilities?
C. auris is a type of fungus (y east) first reported in 2009 in Japan. In recent times there are reported cases and outbreaks of serious illness with C. auris in hospitalise d patients. CDC has made an aler t to hospitals in the U.S. for lookout of C. auris. It has been declar ed as an emerging infection. The reason for concern is: a) C. auris is difficult to diagnose with standard laboratory methods and can also be misdiagnosed in labs without specific technology. This is a serious threat as it may lead to inappropriate treatment. b) It is multidrug resistant which means commonly used antifungal medicines cannot be used for treatment. The combination and/ or higher classes of antifungals use for treatment increase risk of side effect and cost. Finally, C. auris is reported with serious infections like bloodstream and central nervous system infection with a very high mortality risk of 30-60 per cent.
Is C. auris a cause of concern in the Middle East region? What are the precautionary measures you would suggest to the healthcare facility managers for early detection of the spread of this fungus?
C. auris cases have been reported in Middle East from Oman, Kuwait, UAE and Saudi Arabia. Department of Health (DoH), Abu Dhabi in a circular in December 2017 directed all healthcare facilities and professionals to remain vigilant about any such cases. A s precautionary measures for early detection DoH further directed hospital laboratory services to follow CDC recommended microbiology practices to correctly detect and identify C. auris from clinical specimen. Species identification must be done from specimen taken from sterile sites (e.g. blood, cerebrospinal fluid). Laboratory services can also coordinate with communicable disease department, DoH for confirmation of culture at SKMC Laboratory. CDC recommends screening of healthcare contacts of patients tested positive with C. auris. Similar screening of patients coming from countries with high prevalence can be screened.
Are there any standards issued by health associations like WHO to avoid contamination of the fungus?
The mainstay of infection control measures to prevent the spread of C. auris in healthcare settings at present includes: a) Moving the patient with C. auris in a single-patient room and following standard and contact precautions while dealing with infected patients. b) Strict compliance and emphasising adherence to hand hygiene c) Dedicated preferably disposable medical equipment should be used for care of infected patients. All nondisposable medical equipment should be thoroughly cleaned and disinfected after use. d) Cleaning and disinfecting patient care environment and reusable equipment must be done dailyfollowed by terminal cleaning with recommended products after discharge. e) Inter-facility communication about potential/ infected C. auris patient before transfer to another healthcare facility. f) Screening contacts of newly identified case patients to identify C. auris colonisation. g) Conducting surveillance for new cases to detect ongoing transmission. Moreover, misidentification of C. auris as other Candida species is common by various commercial biochemical methods mostly because of the absence of C. auris in the current database. Clinical laboratories should be especially alert to the possibility of C. auris when an isolate is identified by biochemical methods as C. haemulonii. MALDIâ€TOF MS and PCR are currently considered the most efficient to early detect C. auris because of faster turnaround times, the cost and skill involved, however its availability is still an issue in most underâ€resourced laboratories.
The fungus can live on surfaces for weeks if not properly cleaned. What are the recommendations for disinfection of surfaces in case of C. auris outbreak?
C. auris has the ability to persist on both dry and moist surfaces (more than 7 days), including the bed, floors, sinks, etc. It can also be found on human skin, nasal cavities and internal tissues of patients. Studies have showed that the normal surface cleaners like quaternary ammonium compounds are ineffective in eradicating C. auris. The information on hands-free disinfection methods, like UV irradiation, are limited, and CDC recommends that these methods if employed for disinfection must have cycle times similar to those used to inactivate bacterial spores (e.g., Clostridioides difficile). The persistence of fungus makes it mandatory to check the effectiveness of disinfection. Adenosine triphosphate (ATP) based monitoring systems which can detect the amount of or ganic matter that remains after cleaning an environmental surface, a medical device or a surgical instrument are superior, efficient and cost effective methods of detection of adequate disinfection as compared to conventional visual method especially after high risk microbes like Candida, Clostridium difficile, MRSA etc.
Are there any equipments or chemical solutions available to eradicate the fungus from the surface?
Hospital wards, bedding materials, beds, invasive and non-invasive medical devices, clothing of patients, skin and surface wounds etc. should be decontaminated, using chlorineâ€based detergents such as chlorhexidine (0.2%–4%) and hydrogen peroxide vapour.
What are the best practices you would suggest to cleaning service providers to keep a track of these fungal/viral threats?
a) Follow standard operating procedures for testing: The service providers should use CDC or European Protection Agency (EPA) based validation methods for testing the various products in efficacy and safety. b) Comprehensive infection prevention solutions: The service providers should work for a comprehensive infection control and prevention system for healthcare including laboratory and microbiological surveillance systems which ensures good understanding and communication with infection control professionals. This ensures hospitals to have a single window for all its infection control solutions and develop a cost effective and sustainable business model.
c) Surveillance: The service providers must work with both government and non-government based surveillance facilities for keeping a track on emerging and remerging pathogens. d) Research: The service providers should focus on research and development to ensure timely availability of validated infection prevention measures for emerging pathogens instead of knee-jerk response seen after outbreak with these pathogens.
What are the challenges you have been facing in the infection control department?
The challenges at present for infection control department are growing multi-drug resistance among microbes and development of ‘super bugs’. The preparedness for emerging and remerging microbes like C. auris is a major challenge for healthcare and especially infection control department. The ever-increasing complexities of patients mix, comply with changing healthcare regulations, pacing with current medical updates, workspace challenges, lack of adequately motivated staff are other challenges to infection preventionists.