First Cases of Fatal Nosocomial Drug-Resistant Fungal Infection

Thirteen cases of Candida auris (C. auris), a serious and sometimes fatal fungal infection that is emerging globally, have been identified in the United States, according to a November 4, 2016, announcement by the CDC. Seven of the cases occurred between May 2013 and August 2016 and are described in a new CDC report. The other six cases were identified after the period covered by the report and are still under investigation.


Candida auris, an emerging fungus that can cause invasive infections, is associated with high mortality and is often resistant to multiple antifungal drugs. C. auris was first described in 2009 after being isolated from the external ear canal discharge of a patient in Japan. This emerging pathogenic fungus was reported in at least a dozen countries on four continents between 2009 and 2015. C. auris is often resistant to antifungal drugs and tends to occur in hospitalized patients.


The new CDC report is the first to describe U.S. cases of C. auris infection. In June 2016, the CDC issued a clinical alert describing the global emergence of C. auris and requesting that laboratories report C. auris cases and send patient samples to state and local health departments and the CDC. Since then, the CDC has been investigating reports of C. auris with several state and local health departments. The agency expects to continue to investigate possible cases as awareness of the emerging infection increases.


“We need to act now to better understand, contain and stop the spread of this drug-resistant fungus,” said CDC Director Tom Frieden, M.D., M.P.H. “This is an emerging threat, and we need to protect vulnerable patients and others.”


Among the seven cases detailed in the report, patients with C. auris were reported in four states: New York, Illinois, Maryland and New Jersey. All of the patients had serious underlying medical conditions and had been hospitalized an average of 18 days when C. auris was identified. Four of the patients died; it is unclear whether the deaths were associated with C. auris infection or underlying health conditions.


In two instances, two patients had been treated in the same hospital or long-term-care facility and had nearly identical fungal strains. These findings suggest that C. auris could be spread in healthcare settings.


Six of the seven cases were identified through retrospective review of hospital and reference laboratory records. Identifying C. auris requires specialized laboratory methods because it can easily be misidentified as another type of Candida infection, in which case patients may not receive appropriate treatment. Most of the patient samples in the current report were initially misidentified as another species of Candida.


Most of the C. auris strains from U.S. patients (71 percent) showed some drug resistance, making treatment more difficult. Samples of C. auris strains from other countries have been found to be resistant to all three major classes of antifungal medications. However, none of the U.S. strains in this report were resistant to all three antifungal drug classes. Based on laboratory testing, the U.S. strains were found to be related to strains from South Asia and South America. However, none of the patients travelled to or had any direct links to those regions. Most patients likely acquired the infections locally.


“It appears that C. auris arrived in the United States only in the past few years,” said Tom Chiller, M.D., M.P.H., chief of the CDC’s Mycotic Diseases Branch. “We’re working hard with partners to better understand this fungus and how it spreads so we can improve infection control recommendations and help protect people.”


The CDC recommends that healthcare professionals implement strict standard and contact precautions to control the spread of C. auris. Facilities should conduct thorough daily and after-discharge cleaning of rooms of C. auris patients with an EPA-registered disinfectant active against fungi. Any cases of C. auris should be reported to the CDC and state and local health departments. The CDC can assist in identifying this particular type of Candida if needed.


In 2013, the CDC issued a report, Antibiotic Resistance Threats in the United States (2013), describing antibiotic resistance threats in the United States that needed prompt action, including Candida infections. The CDC’s Antibiotic Resistance Laboratory Network is providing additional lab support in four regional laboratories to test anti-fungal susceptibility of Candida species and identify emerging resistance. The CDC is also expanding tracking of this fungus through its Emerging Infections Program. Information gathered through these networks plays a key role in tracking resistance and informing policies and interventions.


See the CDC Announcement


See the CDC Report


Also see the CDC Information Site for C. auris


See also Medical Law Perspectives, June 2016 Report: How Risky Is Going to the Hospital? The Dangers and Liabilities of Healthcare-Associated Infections