Survival, Persistence, and Isolation of the Emerging Multidrug-Resistant Pathogenic Yeast Candida auris on a Plastic Health Care Surface.
26 Jul 2017-Journal of Clinical Microbiology (American Society for Microbiology)-Vol. 55, Iss: 10, pp 2996-3005
TL;DR: Comparisons and quantitative data are compiled essential to understanding the vehicles of spread and the ability of both species to survive and persist on plastic surfaces under controlled conditions, such as those found in health care settings.
Abstract: The emerging multidrug-resistant pathogenic yeast Candida auris represents a serious threat to global health. Unlike most other Candida species, this organism appears to be commonly transmitted within health care facilities and causes health care-associated outbreaks. To better understand the epidemiology of this emerging pathogen, we investigated the ability of C. auris to persist on plastic surfaces common in health care settings compared with that of Candida parapsilosis, a species known to colonize the skin and plastics. Specifically, we compiled comparative and quantitative data essential to understanding the vehicles of spread and the ability of both species to survive and persist on plastic surfaces under controlled conditions (25°C and 57% relative humidity), such as those found in health care settings. When a test suspension of 104 cells was applied and dried on plastic surfaces, C. auris remained viable for at least 14 days and C. parapsilosis for at least 28 days, as measured by CFU. However, survival measured by esterase activity was higher for C. auris than C. parapsilosis throughout the 28-day study. Given the notable length of time Candida species survive and persist outside their host, we developed methods to more effectively culture C. auris from patients and their environment. Using our enrichment protocol, public health laboratories and researchers can now readily isolate C. auris from complex microbial communities (such as patient skin, nasopharynx, and stool) as well as environmental biofilms, in order to better understand and prevent C. auris colonization and transmission.
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TL;DR: Genetic analysis indicates the simultaneous emergence of separate clades of this organism in different geographical locations, which will provide direction for further work in this field of Candida auris.
Abstract: The emerging pathogen Candida auris has been associated with nosocomial outbreaks on five continents. Genetic analysis indicates the simultaneous emergence of separate clades of this organism in different geographical locations. Invasive infection and colonization have been detected predominantly in patients in high-dependency settings and have garnered attention due to variable antifungal resistance profiles and transmission within units instituting a range of infection prevention and control measures. Issues with the identification of C. auris using both phenotypic and molecular techniques have raised concerns about detecting the true scale of the problem. This review considers the literature available on C. auris and highlights the key unknowns, which will provide direction for further work in this field.
341 citations
Cites background from "Survival, Persistence, and Isolatio..."
...albicans on both moist and dry surfaces, indicating the potential significance of environmental contamination (76, 77)....
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TL;DR: 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.
Abstract: Background Candida auris is an emerging and multidrug-resistant pathogen. Here we report the epidemiology of a hospital outbreak of C. auris colonization and infection. Methods 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 interventions. Multivariable logistic regression was used to identify predictors of C. auris colonization and infection. Isolates from patients and from the environment were analyzed by whole-genome sequencing. Results 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 developed 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 colonization 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 Conclusions 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. (Funded by the National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance at Oxford University and others.).
270 citations
TL;DR: The global emergence, biology, challenges with laboratory identification, drug resistance, clinical manifestations, treatment, risk factors for infection, transmission, and control of C. auris are reviewed.
Abstract: Candida auris is an emerging multidrug-resistant yeast that causes serious invasive infections with high mortality. It was first discovered in 2009, and since then, individual cases or outbreaks have been reported from over 20 countries on five continents. Controlling C. auris is challenging for several reasons: (1) it is resistant to multiple classes of antifungals, (2) it can be misidentified as other yeasts by commonly available identification methods, and (3) because of its ability to colonize patients perhaps indefinitely and persist in the healthcare environment, it can spread between patients in healthcare settings. The transmissibility and high levels of antifungal resistance that are characteristic of C. auris set it apart from most other Candida species. A robust response that involves the laboratory, clinicians, and public health agencies is needed to identify and treat infections and prevent transmission. We review the global emergence, biology, challenges with laboratory identification, drug resistance, clinical manifestations, treatment, risk factors for infection, transmission, and control of C. auris.
251 citations
TL;DR: This minireview details the global emergence of C. auris and discusses issues relevant to clinical microbiology laboratories, hospital infection control, and antimicrobial stewardship efforts.
Abstract: Candida auris has emerged globally as a multidrug-resistant health care-associated fungal pathogen. Recent reports highlight ongoing challenges due to organism misidentification, high rates of antifungal drug resistance, and significant patient mortality. The predilection for transmission within and between health care facilities possibly promoted by virulence factors that facilitate skin colonization and environmental persistence is unique among Candida species. This minireview details the global emergence of C. auris and discusses issues relevant to clinical microbiology laboratories, hospital infection control, and antimicrobial stewardship efforts.
234 citations
Cites background from "Survival, Persistence, and Isolatio..."
...auris has been shown to persist on plastics ex vivo for at least 14 days, with viability testing indicating that cells are also capable of entering a metabolically active, but nonculturable, state that persisted for 4 weeks (41)....
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TL;DR: This work identified an isolate representative of a potential fifth clade of Candida auris, separated from the other clades by >200,000 single-nucleotide polymorphisms, in a patient in Iran who had never traveled outside the country.
Abstract: Four major clades of Candida auris have been described, and all infections have clustered in these 4 clades. We identified an isolate representative of a potential fifth clade, separated from the other clades by >200,000 single-nucleotide polymorphisms, in a patient in Iran who had never traveled outside the country.
209 citations
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TL;DR: Candida auris is an emerging healthcare-associated pathogen associated with high mortality, and WGS analysis suggests nearly simultaneous, and recent, independent emergence of different clonal populations on 3 continents.
Abstract: Background: Candida auris, a multidrug-resistant yeast that causes invasive infections, was first described in 2009 in Japan and has since been reported from several countries.
Methods: To understand the global emergence and epidemiology of C. auris, we obtained isolates from 54 patients with C. auris infection from Pakistan, India, South Africa, and Venezuela during 2012-2015 and the type specimen from Japan. Patient information was available for 41 of the isolates. We conducted antifungal susceptibility testing and whole-genome sequencing (WGS).
Results: Available clinical information revealed that 41% of patients had diabetes mellitus, 51% had undergone recent surgery, 73% had a central venous catheter, and 41% were receiving systemic antifungal therapy when C. auris was isolated. The median time from admission to infection was 19 days (interquartile range, 9-36 days), 61% of patients had bloodstream infection, and 59% died. Using stringent break points, 93% of isolates were resistant to fluconazole, 35% to amphotericin B, and 7% to echinocandins; 41% were resistant to 2 antifungal classes and 4% were resistant to 3 classes. WGS demonstrated that isolates were grouped into unique clades by geographic region. Clades were separated by thousands of single-nucleotide polymorphisms, but within each clade isolates were clonal. Different mutations in ERG11 were associated with azole resistance in each geographic clade.
Conclusions: C. auris is an emerging healthcare-associated pathogen associated with high mortality. Treatment options are limited, due to antifungal resistance. WGS analysis suggests nearly simultaneous, and recent, independent emergence of different clonal populations on 3 continents. Risk factors and transmission mechanisms need to be elucidated to guide control measures.
978 citations
"Survival, Persistence, and Isolatio..." refers background in this paper
...Asia (India/Pakistan), Africa, South America, and East Asia (Korea/Japan) show four highly clonal phylogenetic and geographically distinct clades that have emerged independently of one another (9)....
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TL;DR: A single strain of a novel ascomycetous yeast species belonging to the genus Candida was isolated from the external ear canal of an inpatient in a Japanese hospital and indicated that this strain represents a new species with a close phylogenetic relationship to Candida ruelliae and Candida haemulonii in the Metschnikowiaceae clade.
Abstract: A single strain of a novel ascomycetous yeast species belonging to the genus Candida was isolated from the external ear canal of an inpatient in a Japanese hospital. Analyses of the 26S rDNA D1/D2 domain, nuclear ribosomal DNA ITS region sequences, and chemotaxonomic studies indicated that this strain represents a new species with a close phylogenetic relationship to Candida ruelliae and Candida haemulonii in the Metschnikowiaceae clade. This strain grew well at 40 degrees C, but showed slow and weak growth at 42 degrees C. The taxonomic description of Candida auris sp. nov. is proposed (type strain JCM15448T= CBS10913T= DSM21092T).
778 citations
"Survival, Persistence, and Isolatio..." refers background in this paper
...auris has an ideal growth temperature of 37-40°C, and is positive for growth in 10% NaCl/5% glucose medium (1)....
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...The emerging multidrug-resistant yeast Candida auris was first identified and described in a clinical culture from an external ear canal (1)....
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TL;DR: The long survival of these bacteria, including MRSA and VRE, on commonly used hospital fabrics, such as scrub suits, lab coats, and hospital privacy drapes, underscores the need for meticulous contact control procedures and careful disinfection to limit the spread ofThese bacteria.
Abstract: The transfer of gram-positive bacteria, particularly multiresistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE), among patients is a growing concern. One critical aspect of bacterial transfer is the ability of the microorganism to survive on various common hospital surfaces. The purpose of this study was to determine the survival of 22 gram-positive bacteria (vancomycin-sensitive and -resistant enterococci and methicillin-sensitive and -resistant staphylococci) on five common hospital materials: smooth 100% cotton (clothing), 100% cotton terry (towels), 60% cotton–40% polyester blend (scrub suits and lab coats), 100% polyester (privacy drapes), and 100% polypropylene plastic (splash aprons). Swatches were inoculated with 104 to 105 CFU of a microorganism, assayed daily by placing the swatches in nutritive media, and examining for growth after 48 h. All isolates survived for at least 1 day, and some survived for more than 90 days on the various materials. Smaller inocula (102) survived for shorter times but still generally for days. Antibiotic sensitivity had no consistent effect on survival. The long survival of these bacteria, including MRSA and VRE, on commonly used hospital fabrics, such as scrub suits, lab coats, and hospital privacy drapes, underscores the need for meticulous contact control procedures and careful disinfection to limit the spread of these bacteria.
763 citations
"Survival, Persistence, and Isolatio..." refers result in this paper
...Our results are comparable to the life-history traits of problematic nosocomial Gram-positive bacterial pathogens Staphylococcus aureus or enterococci (27)....
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TL;DR: The assumption that microorganisms, including pathogens, “die-off” or “decay” in the marine environment must be re-evaluated, since stressed or nutrient starved cells are unable to grow and be enumerated by standard plate count methods.
Abstract: In a series of microcosm and field studies, we have observed that over time V cholerae and related human pathogens enter a viable but non-culturable state Direct viable counts by epifluorescent microscopy are consistently higher than corresponding plate counts Thus, the assumption that microorganisms, including pathogens, “die-off” or “decay” in the marine environment must be re-evaluated, since stressed or nutrient starved cells are unable to grow and be enumerated by standard plate count methods Furthermore, animal passage reveals pathogenicity persisting for such “non-viable”cells Indirect immunofluorescent microscopy offers a more sensitive detection system for environmental sampling for human pathogens and therefore, a more valid estimation of population size One implication of these findings for the release of genetically engineered organisms is that highly specific methods of detection and monitoring are required, with direct detection by fluorescent antibody the most reliable at the present time
751 citations
TL;DR: This work states that C. parapsilosis infections are especially associated with hyperalimentation solutions, prosthetic devices, and indwelling catheters, as well as the nosocomial spread of disease through the hands of health care workers, which means individuals at the highest risk for severe infection include neonates and patients in intensive care units.
Abstract: Summary: Candida parapsilosis is an emerging major human pathogen that has dramatically increased in significance and prevalence over the past 2 decades, such that C. parapsilosis is now one of the leading causes of invasive candidal disease. Individuals at the highest risk for severe infection include neonates and patients in intensive care units. C. parapsilosis infections are especially associated with hyperalimentation solutions, prosthetic devices, and indwelling catheters, as well as the nosocomial spread of disease through the hands of health care workers. Factors involved in disease pathogenesis include the secretion of hydrolytic enzymes, adhesion to prosthetics, and biofilm formation. New molecular genetic tools are providing additional and much-needed information regarding C. parapsilosis virulence. The emerging information will provide a deeper understanding of C. parapsilosis pathogenesis and facilitate the development of new therapeutic approaches for treating C. parapsilosis infections.
717 citations
"Survival, Persistence, and Isolatio..." refers background in this paper
...auris, environmental survival and persistence properties have been documented for Candida parapsilosis, another colonizer of human skin, which is one of the most common causes of invasive candidiasis (12)....
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...parapsilosis in hospitals can occur via horizontal transfer through medical devices or other external sources, even without prior colonization (12), and may be similar to those of C....
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