An emerging fungal infection — one that’s especially dangerous for patients with weakened immune systems — is the latest risk facing long-term care facilities in Virginia after more than a year of weathering the COVID-19 pandemic.
Called Candida auris, the yeast has been deemed a “serious global health threat” by the U.S. Centers for Disease Control and Prevention thanks to the longevity of its infections and its resistance to antifungal drugs.
The number of cases identified in Virginia is still relatively small — a total of 37 since July 2020. But in a May 7 clinician letter, state Health Commissioner Dr. Norman Oliver warned it represents a more than ten-fold increase compared to the previous two years — a concerning trend experts worry has been driven by coronavirus-related precautions.
“It’s consistent with what we’ve seen in neighboring states,” said Shaina Bernard, the antimicrobial resistance coordinator for the Virginia Department of Health’s Healthcare-Associated Infections Program. “And one of the hypotheses is that it’s due to personal protective equipment and the conservation strategies that have been happening during the COVID-19 pandemic.”
The CDC reports that 30 to 60 percent of infected patients have died, though many have had comorbidities that increased their vulnerability. VDH “does not follow cases prospectively,” Bernard said, and so doesn’t collect data on patient deaths in Virginia.
A growing swell of multidrug resistant organisms, known in the medical community as MDROs, has been worrying public health officials for years. But many are concerned that the ongoing pandemic has presented unique opportunities for them to spread.
As COVID-19 swept through communities and invaded long-term care facilities, a global shortage of personal protective equipment forced medical workers to reuse items such as gowns and N95 masks. Nursing homes, especially, spent months struggling to source basic supplies, and many are still reusing the normally disposable equipment, said Dr. Jim Wright, the medical director of Canterbury Rehabilitation & Healthcare in Henrico (the facility experienced one of Virginia’s first — and deadliest —COVID-19 outbreaks last March).
“Two years ago, you would have picked up an N95 mask, used it once for a single patient, and thrown it away,” he said. “But we’re still using them for an entire shift.” That reuse can spread C. auris from room to room and patient to patient, according to Bernard
Sarah Lineberger, the manager of VDH’s HAI program, said a change in cleaning products could have also contributed to rising cases. With the emergence of COVID-19 came a spate of new products focused specifically on killing the virus. But it’s not clear that all of those disinfectants were equally effective at eradicating C. auris.
Growing concern over the drug-resistant fungus has prompted warnings in surrounding areas including Maryland, Pennsylvania and Washington, D.C., which have also seen an increasing number of cases throughout the COVID-19 pandemic. Virginia Health Commissioner Dr. Norman Oliver put out his own notice in November, warning that hospitals and other health care facilities were experiencing rising numbers of both coronavirus outbreaks and multidrug-resistant organisms.
C. auris, though, merited an individual warning last week, when Oliver urged providers to pay attention to the growing threat. While 37 cases might seem small, Virginia is one of only 14 states that’s recorded more than a single infection, according to the CDC. Even in states with higher counts, including Illinois and New York, cases number in the hundreds.
When it takes root, C. auris is extremely difficult to purge from a health care facility. And while reports of other MDROs actually declined in 2020 — potentially the result of fewer non-COVID-related hospitalizations and a decline in elective surgeries, Bernard said — C. auris was a notable exception.
“We’re still not sure if we’re going to see even more cases of this in 2021,” she added. Fewer samples were sent in for testing last year, raising the possibility that some infections are going undetected. The fungus can grow on ventilators and IV lines and also seems to disproportionately affect patients needing those services. Tracheostomy patients, as well as those who have recently received antibiotics or antifungals, are also at higher risk, according to Oliver’s clinician letter.
Unsurprisingly, most infections in Virginia have hit nursing homes and acute care hospitals, which often house patients recovering from surgery or those who need more intensive, often respiratory based care. VDH didn’t provide the specific names of facilities or a breakdown of how many infections were recorded in different settings. But Bernard said they were consistent with other outbreaks across the country.
“We’re seeing it a little bit more right now in nursing homes,” she said. “And again, that’s because of the long-term acuity of those patients. There’s not as much turnover, so there’s more chances for patients who already have multiple medical conditions to be introduced to this organism.”
A large part of the anxiety surrounding C. auris is the difficulty with detecting it. Not all labs can identify the fungus, and Oliver wrote some that traditional phenotyping methods easily confuse it with other species. Making things even more complicated is the fact that some species of Candida live harmlessly on humans without causing infections. Even C. auris, in some cases, is detected as part of a “colonized” case, when it’s present on a patient without causing any symptoms.
“So when you see the word Candida, make sure you read the next word,” Wright said. So far, his facility hasn’t experienced any cases, and he said he’s not aware of any in the greater Richmond region. But given a still-limited awareness of the fungus — and existing limitations in testing for it — Bernard and Lineberger worry cases are underreported in Virginia.
“This might be the tip of the iceberg,” Bernard said. “Right now, we’re relying on these clinical cases being reported to us. But whenever we’re relying on that, we’re at least a little bit behind the 8-ball in that there’s probably some other cases happening undetected.”
Already, Virginia has seen C. auris infections that couldn’t be linked to a known exposure, indicating the fungus is circulating through the community.
When infections do become serious, options are often limited. Most cases are resistant to fluconazole, a first-line antifungal that’s usually prescribed to patients. Bernard said VDH is seeing more and more cases that are also resistant to an entire class of drugs considered the standard of care for many fungal infections.
“After that, you really don’t have a lot of options for yeast,” she said. “So as soon as you lose that first class and that second class, you kind of have nowhere to go.”