A new and alarming fungal pathogen, Candida auris (C. auris), is catalyzing a global crisis across long-term care facilities. The Centers for Disease Control and Prevention (CDC) announced C. auris to be an increasing threat earlier this year and has stated that it is often resistant to multiple antifungal drugs, spreads easily, and can cause severe infections with high death rates. 

Early detection of C. auris, optimally pre-infection, is the key to setting up early defenses and preventing the spread – but common testing protocols are lagging. Molecular testing, which has been used in infectious disease detection for decades, allows for precise DNA fingerprinting of pathogens and is our best weapon in the fight against C. auris.

Antibiotic use in long-term care

The Agency for Healthcare Research and Quality (AHRQ) reports that antibiotics are among the most commonly prescribed medications in nursing homes. According to their research, about seven out of 10 residents in long-term care facilities receive an antibiotic every year, and up to 75% of those antibiotics are incorrectly prescribed for the respective infection. 

The large-scale, incorrect use of antibiotics is a known cause of developing antibiotic-resistant bacterial strains such as methicillin-resistant Staphylococcus aureus (MRSA), Vancomycin-resistant Enterococcus (VRE), and Clostridium difficile (C. difficile). As the danger of resistant bacteria becomes more well known, we hear the term “antibiotic stewardship” more often, particularly regarding urinary tract infections in nursing home patients. Antibiotic stewardship is an approach that focuses on improving antibiotic use by avoiding unnecessary or inappropriate antibiotics.

The rise of Candida auris

As concluded in the Annals of Internal Medicine, C. auris detection is often elusive due to limitations of outdated standard culture and sensitivity testing. Researchers warned that screening is not currently conducted uniformly across the United States, so the true burden of C. auris cases may be underestimated.

Lessons learned from other nosocomial infections, including C. diff and MRSA, are useful, like developing infection control and antibiotic stewardship practices that facilities can utilize for the rising fungal infection, but C. auris presents new challenges. C. auris can persist in nursing homes on various surfaces for up to 14 days, and poor detection often leads to an inability to employ general infection prevention and control practices.

Furthermore, C. auris is not usually identified with routine microbiology testing. C. auris requires a specific fungal culture that needs to be ordered specially and requires up to seven days to grow. MALDI-TOF Mass Spectrometry (Matrix-assisted laser desorption/ionization time-of-flight mass spectrometry) is a rapid and accurate technique used to identify Candida species. However, clinicians must order this test specifically looking for C. auris.

The future of UTI testing 

A trend to replace traditional urine culture testing for routine urinary tract infections (UTIs) with molecular Polymerase chain reaction (PCR) has demonstrated to be more specific, offer faster turn-around times, and produce information regarding antibiotic resistance genes in bacteria. Identification of resistance genes can help nursing home administrators identify trends in populations for emerging resistance. 

Another potential unforeseen benefit of PCR testing for UTIs may be the incidental detection of C. auris. As Alexander Flemming, the physician and microbiologist best known for discovering the world’s first broadly effective antibiotic substance, penicillin, ironically once said, “One sometimes finds what one is NOT looking for.”

This testing method provides a unique avenue to find patients harboring this pathogen — even without thinking to look for it. Early identification of these individuals will allow nursing homes to implement strict infection control measures to prevent transmission, including:

  • hand hygiene
  • proper use of personal protective equipment (PPE)
  • isolation precautions for infected patients
  • thorough cleaning and disinfecting of patient rooms and equipment

Everyone prescribing antibiotics should consider both their clinical and public health responsibilities. Our goal to “use the right drug at the right time and in the right duration” should extend beyond bacterial infections, as emerging drug-resistant fungal infections, such as C. auris, become a threat. Employing 21st-century molecular testing will prove to be an essential part of true antibiotic and antifungal stewardship.

Joel Diamond, MD, Co-Founder & Chief Medical Officer of Aranscia and Co-Founder of 2bPrecise, has extensive clinical and technology experience. He formerly served as CMIO and chairman of the Physician Advisory Board at the University of Pittsburgh Medical Center, St. Margaret Memorial Hospital, where he facilitated 100% adoption of CPOE in a community hospital. He is a diplomat of the American Board of Family Practice and a fellow in the American Academy of Family Physicians while continuing to care for patients at Handelsman Family Practice in Pittsburgh, PA.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

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