CDC reports Candida auris cases in the U.S.

July 3, 2017 / By Camille Ruiz, RHIA

I was reading a May 2017 article from the Centers for Disease Control and Prevention (CDC) announcing 122 cases of Candida auris (C. auris) in the past nine months across seven states. Prior to 2015, the U.S. had seven cases identified through retrospective chart reviews. Most C. auris infections are treatable with a class of anti-fungals called echinocadins. Like bacteria-resistance to antibiotics, some C. auris strains are resistant to all three common classes of anti-fungals requiring high doses of the multiple anti-fungal classes. C. auris is a type of yeast dubbed a “super bug” due to its resistance to common anti-fungals. 

This yeast was first identified in 2009 in Japan as an ear infection hence the “auris” designation. “Super bugs” must be thought of in global terms for prevention, management and treatment. C. auris has spread to all but one continent in less than a decade. Patients can quickly develop life-threatening conditions when C. auris enters their bloodstream contributing to the high mortality rate. The mortality rate range is between 60-70 percent. Unfortunately, these patients often have other serious illnesses so it is unknown if the C. auris is the cause of death or a contributing factor. Any age or gender can be at risk.  Most of the 122 U.S. cases were male patients with a median age of 70 years. The patients most at risk include:

  • Central venous catheters present
  • Extended ICU stays
  • Nursing home residents
  • Recent surgical wound
  • Long-term use of broad-spectrum antibiotics, anti-fungals or corticosteroids
  • Immunocompromised

C. auris is often misidentified for other common types of yeast infections delaying appropriate treatment and infection control precautions. Patients average 18 inpatient days before being diagnosed. The presence of a Candida isolate listed below and resistance to one or more anti-fungal drug classes should prompt further testing for C. auris:

  • Candida famata
  • Candida haemulonii
  • Candida sake
  • Candida spp. where results are inconclusive
  • Rhodotorula glutinis
  • Saccharomyces cerevisiae

Another factor to the misdiagnosis and delayed treatment is the specialized lab equipment required for correct identification. This specialized lab equipment is not common in standard hospital labs. The two ways for laboratories to identify C. auris consist of:

  • The instrument Matrix-assisted laser desorption/ionization-time of flight mass spectrometry (MALDI-TOF-MS)
  • The Molecular methods sequencing the Internal transcribed spacer (ITS) and D1-D2 ribosomal gene

I for one am not a lab expert so I cannot define either for you. Before your Lab Directors try to submit a Capitalized expense request, remember C. auris is not prevalent in the U.S. It may be more feasible to utilize a reference lab. Some reference labs will forward results to the CDC. I would recommend a review of this practice with any reference lab vendors to avoid any duplication of effort. It is highly recommended to report any C. auris cases to the CDC or local health department but it is voluntary for now. C. auris outbreaks are usually hospital-acquired spreading quickly by direct person-to-person contact, contaminated equipment or surfaces as well as mattresses and linens. An added difficulty of containing C. auris is that it can remain active on surfaces up to 2 days without moisture unlike the typical Candida that require moisture to thrive. Precaution interventions should be implemented once a patient is suspected or diagnosed with C. auris to prevent an outbreak.  Basic infection control measures should include:

  • Implement standard precautions 
  • Use contact precautions
  • Isolate the patient in a private room when possible
  • Notify receiving facility of required precautions when patient is transferred
  • Clean patient’s room and equipment daily with an Environmental Protection Agency (EPA) hospital-grade fungal claim disinfectant

How does C. auris relate to outpatient CDI? These are inpatients, right? Think about the patients who present multiple times to clinics and the Emergency Department with failed outpatient antibiotic therapy before being admitted with more severe conditions than the original compliant. There isn’t a C. auris specific ICD-10 Diagnosis codes.  Start with B37 Candidiasis or P37 Neonatal Candidiasis.  Also use Z1632 Resistance to antifungals.

We may not be able to irradiate “super bugs” any time soon but we can adopt methods to prevent, manage and treat the infections. Early detection and treatment may be the key to containing hospital outbreaks and lowering the mortality rate unless you are prepared to purchase a one-way ticket to Antarctica which I am guessing is the only unaffected continent. You may face more challenges in Antarctica than illness. Until next time, keep coding!

Camille Ruiz is an outpatient CDI consultant at 3M Health Information Systems.

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Tsay S, Welsh RM, Adams EH, et al. Notes from the Field: Ongoing Transmission of Candida auris in Health Care Facilities—United States, June 2016–May 2017. MMWR Morb Mortal Wkly Rep 2017;66:514–515. DOI: