ICMR guidelines for candida auris infection treatment and management

Candida auris, a multi-drug resistant yeast, has been reported to cause cutaneous and invasive infections with high mortality. Indian Council of Medical Research (ICMR) is aware of the numerous outbreaks of C. auris reported globally and from India.

Since 2009, the infection has been reported globally from many countries within a short period of time. The whole genome sequence analysis of the isolates collected from different geographical locations showed minimal difference among the isolates suggesting simultaneous emergence of C. auris infection at multiple geographical locations, rather than spread from one place to another.

The isolation of the fungus from patients' environment, hands of healthcare workers, and from skin and mucosa of the hospitalized patients indicate the agent is nosocomially spreading. C. auris forms non-dispersible cell aggregates and persists for a longer time in the environment in addition to its thermotolerant and salt tolerant properties.

Unlike other Candida species, the fungus acquires rapid resistance to azoles, polyene, and even echinocandin. The conventional phenotypic methods fail to identify the species and require molecular techniques. Candida Auris being a new deadly fungal multi drug-resistant superbug which is expected to grip the entire world and is on verge of becoming a global threat. Alarmingly, it has resulted in the death of 30-60% of people who developed C. auris infections as the Specialty Medical Dialogues had earlier reported in its news report published on April 9, 2019.

In this light, flowing are the key recommendation for diagnosis and treatment of C.auris infection which has been given by ICMR.

C.auris Identification and susceptibility testing: Rapid and accurate identification of C. auris and adherence to infection control practices, along with ongoing public health surveillance and investigations, are needed to combat the spread of C. auris in India.

The agent requires a specialized method of identification, as commonly used automated phenotypic systems like Vitek 2, API20C-AUX, Auxacolor, Phoenix and Microscancanlabel C. auris as C. haemulonii, C. famata, C. sake, S. cerevisiae, R. glutinis, C. lusitaniae, C.guilliermondiior C. parapsilosis. Reliable identification is given by either MALDI-TOF with upgraded database or sequencing of internal transcribed spacer and D/D2 regions of ribosomal DNA. However, it has been 2 observed that C. auris grows at 42° C, but fails to grow in the presence of 0.01% or 0.1% cycloheximide, and can ferment dextrose, dulcitol, mannitol.

Candida auris Treatment is often multidrug resistant and can lead to high mortality (33-72%) in candidemia[11, 18, 19]. At present, the overall resistance pattern is seen as: Resistance to fluconazole - >90%, voriconazole ~ 50%, Amphotericin B –>30%, Echinocandins – 7-10%.

• There is no consensus for optimal treatment due to variation of susceptibility.
• Uniform opinion – fluconazole should be avoided.
• Antifungal susceptibility testing is highly desirable.
• Echinocandins remain the first-line therapy for C. auris infection, however, caspofungin shown to be inactive against C. auris biofilms.
• Flucytosine (MIC50, 0.125–1 µg/ml) has shown good activity for urinary tract infection, but the drug
should not be used alone.
• Posaconazole (range, 0.06–1 µg/ml) shows excellent in vitro activity against C. auris, but no data available on use in patients.

When you should suspect C. auris?

• If the patient is from ICU or high-dependency area
• Transferred from another hospital after a long stay
• Multiple interventions & prior antifungal exposure in any patient
• If one identifies in a commercial system -Candida haemulonii, C. famata,C. guilliermondii, C. lusitaniae, C. parapsilosis, Rhodotorulaglutinis, Candida sake, Saccharomyces cerevisiae
• If the Candida appears to be resistant to fluconazole & high MIC to voriconazole

Infection Prevention Measures for the infected or colonized patient: Standard as well as contact precautions should be implemented while caring for patients with suspected or confirmed C. auris infection.

• Wherever feasible, these patients should be kept in isolated rooms or with other patients with the same infection. Patients with diarrhea may be at a higher risk to transmit the organism to other patients and self-colonization at multiple sites. It may be useful to cohort or semi-cohort these patients away from other patients.
• Hand-hygiene using WHO recommended all six steps should be followed strictly by all staff and patient attendants before and after contact. Both soap and water and alcohol hand sanitizers with or without chlorhexidine have been found to be equally effective in eradicating hand carriage of C. auris. Wearing of gloves should not be used as a substitute for hand hygiene.
• There should be dedicated routine equipment for these infectious individuals (ventilators etc.)
• Catheter care bundles and care of tracheostomy sites.
• If a procedure (e.g. dialysis) has to be performed on an infected or a colonized patient, then he/she should be the last patient of the day, if possible.