Prevention Of Candida Auris And Other Novel Multidrug .
CALIFORNIA DEPARTMENT OF PUBLIC HEALTHPrevention of Candida auris andOther Novel Multidrug-resistantOrganisms in Healthcare FacilitiesDecember 10, 2020Presented via webinar in collaboration with theLos Angeles County Department of Public Health andCenters for Disease Control and PreventionErin Epson, MDHealthcare-Associated Infections (HAI) ProgramCenter for Health Care QualityCalifornia Department of Public Health
2HEALTHCARE-ASSOCIATED INFECTIONS PROGRAMC. auris, COVID-19 Cases in CA through November 30, 2020Number of Candida auris Cases100Number of COVID-19 4030100,0002050,0001000Month and Year
HEALTHCARE-ASSOCIATED INFECTIONS PROGRAMKey Messages COVID-19-related disruptions and challenges have affected everyone – we understand!– Healthcare personnel (HCP) safety concerns, shortages, infection control lapses Candida auris and other novel multidrug-resistant organisms (MDRO) are still public healththreats, with recent resurgence of cases and outbreaks Strategies to prevent C. auris and other MDRO transmission are not new Strengthening basic infection prevention and control practices reduces transmission of bothMDRO and SARS-CoV-2, and protects patient and HCP health and safety Public health resources are available to support MDRO testing and containment3
National Center for Emerging and Zoonotic Infectious DiseasesCandida auris and other novel multidrugresistant organism prevention in long-term carefacilitiesAlfonso C Hernandez, MD MPHLieutenant Commander, U.S. Public Health ServiceEpidemic Intelligence Service OfficerDivision of Healthcare Quality Promotion (DHQP)Epidemiology Research and Innovations Branch
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Objectives1. Describe novel multidrug-resistant organisms (MDROs).2. Describe Candida auris in long-term care settings.3. Describe recent public health investigation related to Candida auris,other novel MDROs and COVID-19 in Los Angeles County (LAC).4. Describe prevention strategies for Candida auris and novel MDROsin long-term care facilities (LTCF).
What are Novel Multidrug-Resistant Organisms(MDROs)?Resistant to all or most antibioticstested, making them hard to treat Are uncommon in a geographicarea or the US (e.g., Candidaauris)ORHave special genes that allowthem to spread their resistance toother germs (e.g., Carbapenemresistant bacteria)
Novel multidrug-resistant bacteria pose a special threat. Carbapenemases are enzymes that makecertain antibiotics, like carbapenems,penicillins, and cephalosporinsineffective.The code for carbapenemases can beshared between strains of bacteria,accelerating their spread.*Carbapenems are the broadest-spectrum antibiotics used in difficult to treat bacterial infections
The language used to describe novel MDROs canbe confusing, but you just need to know the basics.You may hear:CPO carbapenemase-producing organismKPC, VIM, NDM, IMP, OXA-48 carbapenemaseenzymesCRE, CRAB, CRPA multidrug-resistant bacteriaCandida auris novel multidrug-resistant yeastCDC 2019 AR Threats html)CDC CRE Technical technical-info.html)
Carbapenem resistance has spread rapidly throughout the U.S.KPC-CRE found in the US spread from 2 states in 2001 to 50 states, DC, and PR by 2017States with Klebsiella pneumoniae carbapenemase (KPC)-producing Carbapenem-resistantEnterobacterales (CRE) confirmed by CDCTracking CRE in the United tml)
Novel MDROs require more aggressive interventionthan endemic* MDROs.We don’t want novel MDROs to become as commonas endemic MDROs (e.g., MRSA and VRE)Endemic and novel MDROs can be prevented usingthe same infection prevention and control (IPC)principles!*Endemic the constant presence of an agent or health condition within a givengeographic area or populationMRSA Methicillin-resistant Staphylococcus aureus; VRE Vancomycin-resistantEnterococci
Transmission and spread of novel MDROs
Novel MDROs can be prevented by core infectionprevention practices.Hand hygieneCleaning and disinfectionTransmission-basedprecautionsDedicated medicalequipment
Novel MDROs can spread silently if residents/patientsare colonized.Colonization means that a personis carrying a germ but does nothave symptoms of an infection.Colonized patients can spread thegerms to others.Colonized patients can developinfections.
Screening for novel MDROs helps identifycolonized patients and prevent transmission.Facility-wide pointprevalence surveysas part of investigationsScreening newlyadmitted or readmittedpatients
Gaps in interfacilitycommunicationcontribute to novelMDRO spread.Spread of an MDRO AmongMany Healthcare Facilities ina RegionSpread is often amplified inhigh acuity post-acute carefacilities Long lengths of stay High acuity patients Less infection controlinfrastructure than shortstay acute care hospitalsLTACH long-term acute care hospitalWon et al. Clin Infect Dis 2011; 53:532540
Coordinatedcommunicationbetween facilities andhealth departments isessential to preventspread.Making Health Care d/infographic.html)
Containment of novel MDROs is cyclical andrequires early and aggressive response.Hand HygieneCleaning &DisinfectionTransmissionbasedprecautions
COVID-19 presents new prevention challenges fornovel MDROs.Staffing shortagesPPE shortagesABHS shortagesDisinfectant shortagesIncreasedpatient/residentvolume and transfersIncreased infectionprevention programburdenHCP safetyPPE personal protective equipment; ABHS alcohol-based hand sanitizer; HCP healthcare personnel
Candida auris
Candida auris is an emerging multidrug-resistant yeast(a type of fungus) that can cause severe infections.
Clinical cases of Candida auris have continued toincrease since its first detection in the United States.
Candida auris affects the sickest of the sick. Multiple healthcare stays Tracheostomies Ventilator-dependent Colonized with otherMDROs Recently received antibioticsand antifungals
vSNFs and LTACHs are disproportionately affectedwhen compared with traditional skilled nursingfacilities (SNFs).Data from investigation in Illinois and New York, unpublishedvSNF skilled nursing facilities with ventilator units; LTACH long-term acute care hospitals
Patients with Candida auris are oftencolonized indefinitely.Persist for many monthsCurrently, no decolonizationstrategiesPrimarily on skin Nares Armpit Groin
Of patients colonized with Candida auris 5-10%develop bloodstream infections.Mortality is 45% within the first 30 days
Misconception: Healthcare personnel (HCP) canbecome easily colonized when caring for patientswith Candida auris.HCP are at minimal risk of colonization.An investigation in a facility with a Candida auris outbreak found thatout of 700 HPC caring for patients with Candida auris, none werecolonized.
Candida auris persists in the environment for a long time.time.
Candida auris can also contaminate medicalequipment.
From a single introduction, Candida auris canspread rapidly.vSNF skilled nursing facility with ventilator units; PPS point-prevalence survey Slide courtesy of Chicago Department of Public Health.
From a single introduction, Candida auris can spreadrapidly, cont.vSNF skilled nursing facility with ventilator units; PPS point-prevalence survey Slide courtesy of Chicago Department of Public Health.
Novel MDROs travel together.vSNF skilled nursing facility with ventilator units; PPS point-prevalence survey; CPO carbapenemase-producing organismSlide courtesy of Chicago Department of Public Health.
Investigation Candida auris and COVID-19 in LosAngeles County (LAC): Investigation
Responding to increased detection of Candidaauris in long-term care facilities.
LAC and CDC's coordinated public healthresponse had three objectives.1. Assess infection prevention and control (IPC) program,infrastructure, and practices in LTACH and vSNF facilities withrecent or ongoing novel MDRO outbreaks or at risk of futureoutbreaks to identify factors contributing to MDRO transmission.2. Identify IPC changes in response to the COVID-19 pandemic thatcould contribute to re-emergence of novel MDROs, including howfacilities were implementing surge capacity strategies.3. Use findings to inform additional education and recommendations.vSNF skilled nursing facility with ventilator units; LTACH long-term acute care hospital
Assessment of IPC practices included questionnaire and directobservations. IPC program staffing MDRO detection,management, andprevention Facility staffing Hand hygiene Cleaning and disinfection PPE supply and usagePPE personal protective equipment Facility layoutPPE useHand hygieneEnvironmental cleaning
We visited 12 facilities: 4 LTACHs and 8 vSNF,5 facilities had Candida auris and 2 had CPO. Staffing, hand hygiene, cleaning and disinfectant, and PPE shortages werecommon. No significant differences in practices were found between facilities withCandida auris or CPO and those without.LTACH long-term acute care hospital; vSNF skilled nursing facility with ventilator units; CPO carbapenemase-producingorganism
We identified several strengths in our IPC assessment.All facilities had infection prevention programs.ABHS was generally available but not as much as would be ideal.Most facilities stocked disinfectants effective against Candida auris.ABHS alcohol-based hand sanitizer
We identified common IPC gaps that maycontribute to C. auris spread. Preference of soap and water over ABHS Missed HH opportunities when entering and exiting resident rooms ABHS not available outside and immediately inside resident rooms Inadequate measurement and mixing when self-preparing bleach Missed high touch surface cleaning and disinfection Infrequent cleaning of mobile medical equipmentABHS alcohol-based hand sanitizer; HH hand hygiene
We identified common IPC gaps that may contribute toC. auris spread, cont. Double gowning and double gloving Using gowns with back untied Re-use of disposable gowns Not changing PPE between patients in the same room Confusing or contradictory transmission-based precautionssignage Cohorting patients by organism, site of infection, andinfection type (i.e., colonization or active) resulting infrequent/unnecessary patient movementPPE personal protective equipment
Preventing MDRO Spread Within Your Facility
Hand hygiene
Misconception: Hand hygiene with soap and wateris superior at killing organisms on hands than ABHS.ABHS is better than handwashing at killing bacteria.ABHS is less damaging to the skin than soap and water.ABHS is preferred method of hand hygiene for most clinical situations.ABHS alcohol-based hand sanitizerCDC Hand -hygiene.html)
Remember the 5 key moments for hand hygiene.1. Before touching apatient2. Before clean/asepticprocedures3. After body fluidexposure/risk4. After touching a patient5. After touching patientsurroundings
Misconception: HCP should perform handwashing with soapand water after 3 resident contacts to reduce transmissionof organisms.Indications for handwashing with soap and water: When hands are visibly soiled After caring for a person with known or suspected infectious diarrhea After know or suspected exposure to spores (for example in Clostridioidesdifficile outbreaks)
After glove doffing and moving from dirty to clean whencaring for a patient are two frequently missedopportunities for hand hygiene.Gloves are not a substitute for hand hygiene
Make it easy to perform hand hygiene for staff and others. Provide immediate access to ABHS atevery point of care Inside and outside of residentrooms (ideally at each bed space) Common areas Staff workstations Therapy rooms Have a plan for restocking supplies Avoid “topping off” ABHS or soapdispensers to avoid environmentalcontamination
Develop a training, auditing, and feedback system. Create a culture of safety Competency-based training Caught red-handed Fluorescent gel hand washingexercise Develop an auditing and feedbackprogram “Secret shopper” Record data Provide feedbackCDC Hand Hygiene: Education, Monitoring and Feedback e/HH102-508.pdf)
Cleaning and disinfection
Cleaning and disinfection are separate andcomplementary processes.Cleaning is the removal of foreign material (e.g., soil, and organicmaterial) from objects.Disinfection is the thermal or chemical destruction of pathogenic andother types of organisms.Thorough cleaning is required before disinfection (unless a product isspecifically labeled as a combined cleaner and disinfectant) becauseinorganic and organic materials interfere with the effectiveness ofdisinfectants.
Contact/Wet Time is the amount of time that adisinfectant must remain on a surface to be effective.Consider labeling products with contacttimes to ensure all staff use disinfectantsappropriately
Focus cleaning high-touch areas frequently
Make sure shared medical equipment is cleanedand disinfected after each patient.
Misconception: All hospital-grade disinfectantseffective against SARS-CoV-2 are also effectiveagainst Candida auris. Most quaternary ammonium chloride (“Quats”) compounds are noteffective against Candida auris. All disinfectants approved for Candida auris are effective againstSARS-CoV-2 and other novel MDROs.
There are several options when choosing a producteffective against Candida auris. First choice: Products with EPAregistered claims againstCandida auris Second choice: Products testedby CDC effective against Candidaauris Third choice: Products in EPA’sList K effective againstClostridioides difficile sporesAntimicrobial Products Registered with EPA forClaims Against C. auris gistereddisinfectants#candida-auris)C. auris Infection Prevention and fection-control.html)Section 18 Public Health Exemption n-18-public-health-exemption-508.pdf)List K: EPA’s Registered Antimicrobial ProductsEffective against Clostridium difficile nst-clostridium)
When using self-prepared bleach pay attention totype, dilution, and storage.Always follow manufacturers’instructions for proper use ofdisinfecting (or detergent) productsincluding proper protective equipmentneeded.Use germicidal bleach intended forhealthcare settings and not generichousehold bleach.Surfaces need to be cleaned beforeapplying bleach or else it will beinactivated.OSHA NIOSH Info Sheet: Protecting Workers Who Use Cleaning Chemicals (PDF)(www.osha.gov/Publications/OSHA3512.pdf)
When using self-prepared bleach pay attention totype, dilution, and storage, cont.5.25-6.15% sodium hypochloritesolution 1 part bleach, 9 parts waterdilution (1:10) required to killClostridioides difficile andCandida auris Accurately measured and wellmixed Make your bleach solution dailyif possible and stored in anopaque container, as bleach islight-sensitiveSection Navigation Rationale and Considerations for ChlorineUse in Infection Control for Non- U.S. General s/non-us-healthcaresettings/chlorine-use.html)
Effective strategies to improve cleaning and disinfectioninclude:1. Assign clear disinfectionresponsibilities2. Develop an audit andfeedback program3. Make disinfectants availableto all staff4. Train staff on proper cleaning,disinfection, and product use.Appendices to the Conceptual Program Model for ppendices-evaluating-environcleaning.html)
Strongly consider using disinfectants effectiveagainst Candida auris even if there have been nocases identified in your facility!
Transmission-based precautions
Gowns and gloves are recommended to care forresidents colonized/infected with C. auris and othernovel MDROs.
Complicated signage can lead to improper PPE use.Difficult to read due to small fontand color contrastUnnecessary level of detail – colorcoding for site ofcolonization/infectionDoes not mention need fordedicated medical equipment
PPE use signage should be consistent.Avoid placing to many signstogether which may haveconflicting information.
Signs should clearly communicate the level of precautions, PPE needed,and any other special considerations and be immediately outsidepatient’s room.CDC Transmission-based precautions ased-precautions.html)
Proper donning and doffing will minimize the risk fordisease transmission.CDC Using e.html)
Misconception: If a resident/patient who was previouslyknown to be colonized with Candida auris testsnegative for colonization contact precautions can beremoved. Colonization with C. auris can last for prolonged periods of time and isnot always detected. Routine rescreening of individuals is not recommended. Decisions to discontinue Contact Precautions should be made inconsultation with health department.
Patient placement and cohorting considerations
Private rooms are preferred and prioritize patientswith uncontained secretions or excretions.
If cohorting, prioritize pathogens and keep itsimple:1. COVID-192. Candida auris and/or other MDRO status Remember that C auris persists in the environment, rooms requirethorough environmental cleaning after any patient movement Beds at least 3 feet apart Each resident and surrounding environment should be treated asseparate areasColonization vs active infection and the anatomic site of positivespecimen should not be considered when making cohorting decisions.
Remember that novel MDROs travel together andpatients may have multiple organisms.PPE should beremoved, and handhygiene performedbefore providingcare to anotherresident, even inthe same room toavoid crosscontaminationSlide courtesy of ChicagoDepartment of Public Health.
COVID-19 strategies for optimizing PPE supplies
Surge capacity strategies are a framework to approach adecreased supply of PPE during the COVID-19 response.Published by CDC in February after thefirst few cases were reported in theUnited States and CDC startedbecoming aware of impending PPEshortages.CDC developed the burn ratecalculator to help facilities optimizethe use of PPE during the COVID-19response.CDC PPE Burn Rate pestrategy/burn-calculator.html)
Surge capacity strategies should be implemented sequentially.Surge capacity refers to the ability to manage a sudden increase in patientvolume that would severely challenge or exceed the present capacity of a facility.Optimizing the Supply of PPE in Healthcare )
Strategies for Optimizing the Supply of GownsConventionalContingencyCrisisUse isolation gown alternatives that Consider the use of coveralls.offer equivalent or higher protection.Extended use of isolation gowns.Polyester or polyester-cotton fabricscan be safely laundered after eachuse and reusedPrioritize gowns:Use of gowns beyond themanufacturer-designated shelf lifefor training. Splashed and sprays anticipated,including aerosol generatingprocedures High-contact activities: Dressing, bathing/showering,providing hygiene, assisting withtoileting Transferring, changing linens Device care, wound careUse gowns or coveralls conforming to Consider using gown
1. Describe novel multidrug-resistant organisms (MDROs). 2. Describe andida auris C in long-term care settings. 3. Describe recent public health investigation related to Candida auris, other novel MDROs and COVID-19 in Los Angeles County (LAC). 4. Describe prevention strategies for Candida auris and novel MDROs in long-term care facilities (LTCF).
Men can get genital yeast infections caused by Candida just like women can. Candida albicans cannot ferment lactose unlike any of the other Candida species. What is Candida? Candida is a yeast that normally lives in and on the body of humans (and other animals, insects) but that g
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The Candida Diet Avoid carbohydrates: Supporters believe that Candida thrives on simple sugars and recommend removing them, along with low-fiber carbohydrates (eg, white bread). Avoid yeast-containing foods: Examples include beer, wine, vinegar, baked goods, and mushrooms. Use probiotics: Advocates say this will help intro
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This checklist is most relevant for environmental fungi like Aspergillus spp. and mucormycetes. It is less relevant for fungi like Candida auris that involve skin colonization and disperse through inadequate hand hygiene and environmental disinfection; assessment of adherence to infection control practices and environmental cleaning and
Colonized with other multidrug-resistant organisms Recently received antibiotics and antifungals Overnight hospitalization outside U.S. Longerm acute care (LTAC) hospital -t or ventilator-equipped skilled nursing facility (vSNF) stay
teaching 1, and Royal Colleges noting a reduction in the anatomy knowledge base of applicants, this is clearly an area of concern. Indeed, there was a 7‐fold increase in the number of medical claims made due to deficiencies in anatomy knowledge between 1995 and 2007.
