Updates: Candida Epidemiology and Candida auris

Transcription

1 National Center for Emerging and Zoonotic Infectious Diseases Updates: Candida Epidemiology and Candida auris Tom Chiller MD MPHTM Chief, Mycotic Diseases Branch My usual Disclosure! 1

2 Candidemia surveillance 2

3 Incidence per persons % Resistant Candidemia incidence by year and EIP site, Overall incidence: ~7/100, MD TN GA NM: 5.3 OR: 4.9 CA: 4.8 MN: OR Year CA CO GA MD MN NM NY OR TN CO: 4.3 Fluconazole Resistance (all species) by EIP Surveillance Site (n=~8000 isolates) 16.0% 14.0% 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% On average, ~7% of all isolates collected through EIP are resistant to fluconazole (intrinsic or acquired resistance) 14.3% 9.5% 5.7% 4.7% 4.1% 2.3% 1.8% OR,CA: 0.0 % Year CA CO GA MD MN NM NY OR TN 3

4 % Resistant % Resistant Echinocandin Resistance (all species) by EIP Surveillance Site (n=~ 8000 isolates) 15.0% 13.0% 11.0% 9.0% 7.0% 5.0% 3.0% 1.0% On average ~ 1.5% of all isolates are resistant to echinocandins 1.9% 1.8% 1.7% 1.4% CA CO GA MD MN NM NY OR TN -1.0% Year CA, NM, NY, OR, TN: 0.0% Echinocandin-resistant C. glabrata by Surveillance Site (n=2230 isolates) 15.0% 13.0% 11.0% 9.0% 7.0% 5.0% 3.0% 1.0% -1.0% On average ~ 4% of C. glabrata isolates are resistant to echinocandins Year 6.5% 6.3% 5.9% 3.6% CA CO GA MD MN NM NY OR CA, NM, NY, OR, TN: 0.0% TN 4

5 Resistance US surveillance C. albicans still causes the highest percentages of Candida infections Fluconazole resistance for C. albicans is <1% Overall fluconazole resistance is ~7% Majority of this is C. glabrata and C. krusei Echinocandin resistance for C. albicans, C. tropicalis, C. parapsilosis, and C. krusei has remained <1% C. glabrata MDR in the US 1.1% of all C. glabrata isolates were resistant to both fluconazole and echinocandins 28% of all echinocandin resistant C. glabrata are fluconazole resistant 11% of all fluconazole resistant C. glabrata are echinocandin resistant 5

6 Proportion of Cases who Inject Drugs (%) Candidemia burden estimate in 2017 Based on projection from 1200 cases collected through EIP surveillance in 2017: 23,000 cases of candidemia occur each year in the United States 3,000 deaths (all cause mortality within 1 week of candidemia) Projected incidence rates of candidemia, by census division (per 100,000 population) Tsay et al, ID Week 2018 Proportion of IDU-associated candidemia cases by site, % 25% OVERALL: 10.2% 29.4% 25.8% 20% 15% 16.7% 16.3% 10% 5% 0% 7.8% 8.6% 4.8% 3.9% 1.4% CA CO GA MD MN NM NY OR TN Site Zhang et al, ID Week

7 Incidence per persons Proportion of cases who inject drugs (%) Trends in Proportion of IDU by year and site, at select site with previous years of data 30% 25% OR 20% 15% Tripling of proportion of cases TN MD 10% 5% GA 0% Year Candidemia incidence by year and EIP site, Note increases in incidence of candidemia in TN likely due to increases in IDU MD NM: TN GA OR Year CA CO GA MD MN NM NY OR TN OR: 4.9 CA: 4.8 MN: 4.7 CO: 4.3 7

8 Summary One in 10 candidemia cases are associated with IDU in 2017 Increase since 2014, most notably in TN and MD Significant differences between IDU-associated candidemia cases and non- IDU cases Median age: 35 vs. 62 years Hepatitis C: 55% vs. 6% TPN: 5% vs. 27% In-hospital mortality: 9% v. 27% CDC is investigating IDU-associated candidemia in more detail Antimicrobial Resistance Labortory Network (ARLN) 8

9 ARLN Labs Candida part of CORE pathogens tested Objectives of the Candida ARLN program Set up regional lab network for susceptibility testing Track antifungal resistance among Candida/yeast species Identify emerging resistant species like Candida auris 9

10 468 isolates tested in Northeast Central Southeast West 10

11 Species identified Top Resistance: C. glabrata (n=97) 15.5% 3.1% Azoles Echinocandins 1.1% Micafungin 2 isolates azole and echinocandin resistant 11

12 169 isolates confirmed as C. auris 36% of all isolates 95% of all isolates identified as C. auris by the submitter 120 unique patients Northeast Central Southeast Number of isolates Number of patients C. auris update 12

13 Candida? A paradigm shift for Candida infections A Yeast that acts like a Bacteria! Resistance is the norm Thrives and persists on skin Contaminates patient rooms SPREADS IN HEALTHCARE SETTINGS 13

14 C. auris epidemiology Countries with Candida auris through

15 Number of clinical cases Countries reporting Candida auris in 2018 Some hospitals with 40% candidemia C. auris clinical cases reported by state United States, 2013 August ~425 clinical cases ~1180 clinical + screening cases New York New Jersey Maryland Illinois California Massachusetts Solid: Confirmed case Striped: Probable case 15

16 Percent resistant States from which C. auris cases have been reported Epidemiologic Characteristics of U.S. Cases Initial culture site of C. auris Median age: 70; ~30% 30-day mortality Multiple underlying conditions, indwelling devices Tracheostomy, central line, gastrostomy tube Extensive healthcare exposure Acute care hospitals, LTACHs, vsnfs Antifungal resistance of C. auris Patient have multiple other MDROs CP-CRE is the most common co-colonizer 16

17 Healthcare abroad is risk factor for C. auris US C. auris cases are a result of initial introductions from abroad followed by local transmission African clade East Asian clade South Asian clade Isolates from U.S cases cluster to all four C. auris clades >300 clinical cases > 700 additional patients colonized South American clade Chow et al, Lancet ID in press 17

18 CT, CA, and OK travel-related cases South Asian clade India Connecticut (CT) India California (CA) Pakistan Oklahoma (OK) Chow et al, Lancet ID in press Global C. auris antifungal resistance Echinocandins Amphotericin B Fluconazole N= % Resistance 18

19 # of isolates Resistance is clone-specific Southeast Asia Nearly universally Flu R, 40% AmpB R South America Colombian isolates 25% Flu R + AmpB R Venezuelan isolate are universally Flu R Overall 8% Echino R but higher in Venezuela Africa Variable resistance, mostly Flu R, some AmpB R East Asia Universally susceptible Resistance in C. auris is acquired, not intrinsic MIC ug/ml MIC ug/ml 19

20 MDR C. auris Pan resistant 2 or more classes 1 or more class Pan susceptible N= % Resistance C. auris nationally notifiable in

21 C. auris Colonization: A new area for mycologists C. auris Colonization Patients remain persistently colonized NYS has followed a few hundred patients 60% 90-day mortality Some colonized for over a year Only ~16 have cleared colonization Colonization means patients are: At risk for developing invasive infection 30 cases of BSI in ~600 colonized patients who are being followed Source of transmission to others 21

22 C. auris Colonization Most sensitive (>90%) and costeffective swab: axilla and groin Nares, rectal, and oral swabs have also been positive, but not as consistently as axilla/groin swabs Detection through colonization screening Axilla and groin swabbing Enrichment broth method High salt/temperature ~25% more sensitive than direct plating Must hold plates for 10 days 22

23 Question about When/Who to screen? Contact tracing around a newly identified case Point prevalence surveys in places with some documented transmission Admission screening (pilot in NYS) Screening of patients with history of healthcare abroad, especially with a bad MDRO like CP-CRE Screening of patients in high-acuity long-term care facilities, especially those with CP-CRE and other MDROs Rapid diagnostics Real-time PCR 23

24 Decolonization/source control Chlorhexidine? Another agent Antifungals? terbinafine? Remove pressure of antibiotics and antifungals? Candida vaccine? In vitro data on chlorhexidine looks good Schelenz, Federation of Infection Societies Poster,

25 But In vivo studies on reduction in burden of colonization have not been done Facilities where C. auris outbreaks have occurred have not seen improvements in incidence of colonization even when using aggressive CHG bathing Environmental disinfection 25

26 C. auris contaminates the hospital environment Able to survive and persist on surfaces for weeks Other places where C. auris has been cultured from: Temperature probe Madder et al (U.K.), biorxviv 2017) Armstrong et al, unpublished 26

27 Environmental disinfection: Quats don t work well Limited data Recommended but challenging Not recommended Cadnum et al Environmental disinfection Hydrogen Peroxide In vitro studies promising Need real world assessments Schelenz, Federation of Infection Societies Poster,

28 Environmental disinfection UV Light Needs long exposure time at high intensity Cadnum et al 2017 Questions about environmental disinfection What products to use? When to use? Just for case patient room? The whole floor where the patient is admitted there? Pre-emptively at all long term care facilities with ventilated patients in an endemic area? 28

29 Challenges for C auris Screening/colonization testing is not widely available and culture testing takes 10 days to call negative Rapid diagnostics are being developed but are not yet widely available Need decolonization methods Environmental disinfection options are limited (effective and safe alternatives to bleach are needed) Where is it coming from? 29

30 We need to live in Balance with the environment 30

31 Estimated U.S. Agricultural Triazole Use (Metric Tons) Increasing Triazole Use in Agriculture US Data High Estimate Low Estimate Year Source: USGS Pesticide Data Use Project 31

32 For more information, contact CDC CDC-INFO ( ) TTY: Contact us at: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. 32