Hospital Infection Nightmare: Fungus Candida auris

"Typically, we have never really been concerned about fungi or yeast spreading from person to person."
"It seems to be acting a little bit differently. We haven't really thought about fungi this way before."
"It highlights that we are still vulnerable to infectious disease. We will not be able to rely on antibiotics forever."
"Should [Canadians] be worried? In Canada we are doing a pretty good job so far in containing it. We haven't had the same experience as is happening in the States."
"I would say from the community level, I would not worry about it. But it is a good thing to talk about."
Dr.Julianne Kus, clinical microbiologist, Public Health Ontario

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In Winnipeg, a resident who had been to India became a patient in a local hospital in 2017. That 64-year-old is now recognized as Canada's Patient Zero, the first individual to bring back a new threat steadily emerging across the globe, hitting hospitals everywhere and placing them on high alert. Having undergone dental surgery in India, the individual became infected with a drug-resistant bacteria called Candida auris, a fungal infection found in the person's ear after being drained and tested.

This is an infection resistant to multiple drugs, one able to spread from patient to patient. Candida auris is able to live on skin, walls, curtains, handles, cellphone; virtually any surface. It poses little risk to healthy patients, but can colonize the skin of patients with seemingly no deleterious impact. They, in turn can communicate the bacteria to others with suppressed immune systems, causing a serious infection that can enter their bloodstreams and can result in lethality.

It flourishes in some countries as a now-common infection, and there mortality rates for people with invasive Canadida auris are above 50 percent with limited treatment options, making it a viral and often-deadly threat difficult to eradicate. Hospitals in particular view its impact with alarm, since it is there that populations of patients with suppressed immune systems congregate; undergoing cancer treatment or transplants, as an example.

To complicate matters even further, Candida auris is difficult to identify, diagnose, treat and contain; it is particularly persistent. "I think it is something that all hospitals are worried about", remarked Dr. Kus at Public Health Ontario. Thus far, Canada has recognized 19 cases of Candida auris. A cluster of cases in British Columbia, and five others in southern Ontario, although none of the cases surfacing in Ontario was multi-drug resistant.

Candida auris was identified first in 2009 in Japan. Since then it has morphed into a global threat, behaving differently than other infectious threats; its ability to cling to synthetic surfaces to form a biofilm makes it particularly difficult to eradicate. While humans are normally colonized with various strains of Candida which can sometimes cause infections like vaginal yeast and athlete's foot, those strains are considered a nuisance, rather than serious infections.

Treatment for fungal infections is limited, posing yet another complication with Candida auris. Aside from which antifungal drugs can be harmful, and this being the case, they must be judiciously used to avoid harm. Advice to physicians from Public Health Ontario is that rooms of patients or residents colonized with C.auris must be cleaned and disinfected on a daily basis; even twice daily -- with medical equipment used only on that patient, none others.

Ultraviolet light holds out hope as a treatment to eradicate its presence, and evidence exists that hydrogen peroxide vapour together with ultraviolent light can be capable of reducing levels of environmental contamination with C.auris. It is as yet unknown whether this will ultimately reduce transmission rates.

Stephanie Spoor, second from the right, is pictured here with her family. The Chicago woman died in February after contracting a drug-resistant superbug in hospital. (Submitted by Jason Spoor-Harvey.)
Stephanie Spoor, 64, died in February after contracting the fungal superbug Candida auris at Chicago's Northwestern Memorial Hospital while awaiting a lung transplant. She had lived with lupus for years, but the infection killed her within weeks.

 

Growing Incidence of Deadly Fungal Threat: Candida auris

"Everything was positive -- the walls, the bed, the doors, the curtains, the phones, the sink, the whiteboard, the poles, the pump."
"The mattress, the bed rails, the canister holes, the window shades, the ceiling, everything in the room was positive [for the presence of Canadida auris; fungal germ]."
Dr. Scott Lorin, Mount Sinai Hospital, Brooklyn, New York

"It's an enormous problem [explosion of anti-fungal treatment-resistant fungi]."
"We depend on being able to treat those patients with anti-fungals."
Matthew Fisher, professor of fungal epidemiology, Imperial College London

"It is a creature from the black lagoon [the Canadida auris fungus]. It bubbled up and now it is everywhere."
"[Candida auris is] causing invasive infections globally. It acquires resistance fast, and then it remains resistant. It has the ability to develop pan resistance."
"It’s not acting like a typical candida. This candida is acting much more like a bacteria. We’re not used to yeast acting that way. It’s been challenging to identify, but we’re getting better at doing that."
"To me right now the threatening part is in the sickest of the sick. Those patients who have medically invasive procedures, who are hospitalized. Those are the real at-risk patients."
Dr. Tom Chiller, head, fungal branch, Centers for Disease Control

People with weakened immune systems due to illness or age are more likely to be infected with candida auris.

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Antibiotics and antifungals are considered essential tools in combating peoples' infections. But then commercial interests thought it would be a great idea to market antibacterial soaps as a cleanliness and personal hygiene feature and the public in turn responded by buying all manner of soaps that were advertised for their antibiotic content. At the same time veterinarians widely approved of antibiotics for use in farm animals for the prevention of disease, while antifungals have been widely utilized in the prevention of rotting in agricultural plants.

Scientists eventually discovered that this careless wholesale use of fungicides applied to crops has contributed to a surge in drug-resistant fungi that infect humans, just as the epiphany that bacteria became skilled in outwitting anti-bacterials by undergoing swift genetic changes to make them less vulnerable to the effects of the anti-bacterials, eventually morphing into deadly bacteria where infections that became deadly to people with compromised immune systems invaded hospitals.

In the past five years the fungal germ Candida auris has spread swiftly across the globe. Candida auris invaded a neonatal unit in Venezuela, swept through a hospital in Spain, did the same to a British medical centre, forcing it to close its intensive care unit -- and India, Pakistan and South Africa have all suffered the emergence and threats associated with this deadly germ to their most vulnerable populations; the elderly, the very young and the immune-compromised.

New York, New Jersey and Illinois have more recently been invaded with Candida auris to the extent that the federal Centers for Disease Control and Prevention now labels it an "urgent threat", adding it to a list they maintain containing other disturbingly lethal bacterial threats. In May, Mount Sinai Hospital admitted an elderly man for abdominal surgery, when a blood test revealed the C.auris fungus infection. He died at the hospital, but C.auris hung on there.

Subsequent tests revealed that the fungus had invaded his hospital room so completely that special cleaning equipment was required to eradicate it, including the need to rip out part of the ceiling and floor tiles to ensure it was completely destroyed. This is a fungal germ that is impervious to major antifungal medications, revealing it to be an example newly on the scene of one of the world's most intractable health threats concerning health authorities: drug-resistant infections.

That the overuse of antibiotics has led to the effectiveness reduction of drugs by altering bacterial composition to allow them to elude the suppressive effects of antibiotics is well known; the campaign to convince the medical community to prescribe fewer antibiotics -- when to do so is inappropriate or unnecessary -- is decades old. What is new is the growing lethality of fungal infections for which antifungals are increasingly ineffective.

The public has been largely unaware of this newly growing problem, since health authorities want people to have confidence in their hospitals, not fear having to enter them only to contract infections. Hospitals have always been a breeding ground for infections, since they are where people who are ill and who carry infections tend to congregate. Transmission of infections has been fairly well controlled until recent decades, with the emergence of bacteria resistant to eradication.

Yet, once established in a hospital they are increasingly difficult to expunge. And once there are readily spread; carried on hands and equipment within hospitals, present on meat and vegetables fertilized with mature on farms transported by travellers and by exports and imports across international borders as well as patients from nursing homes to hospitals and back again aiding their transfer.

C.auris has turned out to be one of the most dangerous bacteria and fungi that have developed resistance. Over 90 percent of C.auris infections are resistant to one drug and 30 percent are resistant to two or more. "It's pretty much unbeatable and difficult to identify" as "the top" threat among resistant infections is how C.auris, was how it was described by Dr. Lynn Sosa, deputy state epidemiologist  in Connecticut.

According to the Centers for Disease Control, close to fifty percent of patients contracting C.auris will die within 90 days. Despite which researchers have not yet succeeded in discovering where this malignant threat to human health first surfaced. Dr. Johanna Rhodes, an infectious disease expert at Imperial College London recalls a panicked call in 2015 from the Royal Brompton Hospital. The hospital was unable to clear C.auris which had infested the hospital.

"We have no idea where it's coming from. We've never heard of it. It's just spread like wildfire", the hospital informed Dr. Rhodes.

A non-auris form of Candida from a liver sample is shown under a microscope.

CDC PHIL