Study Shows Broader Screening Methods Help Prevent Spread of Dangerous Fungal Pathogen in Hospitals

Screening high-risk patients for Candida auris allows for early detection and implementation of infection control measures to prevent hospital outbreaks

Arlington, Va. - October 31, 2024 - A new study published today in the American Journal of Infection Control (AJIC) describes the outcome of a shift in hospital screening protocols for Candida auris, a dangerous and often drug-resistant fungal pathogen that spreads easily in hospital environments. A comparison of screening results and patient outcomes before and after the change at Mount Sinai Brooklyn, demonstrates the value of broader screening of high-risk patients. As a result of expanded screening, more cases were caught early, enabling infection prevention and control teams to isolate them before they could infect other patients or contaminate shared hospital equipment.

C. auris is an emerging fungal pathogen, first identified in 2009 and now found around the world. While the Centers for Disease Control and Prevention and other public health agencies recommend screening patients admitted to the hospital to identify anyone colonized by the pathogen, there are many different approaches to screening. Broader screening catches more cases, but it requires more resources and can be impractical in healthcare facilities where patients cannot easily be isolated while results are generated.

The study published today in AJIC was triggered by the case of a single patient. The patient was moved from a skilled nursing facility to the Mount Sinai Brooklyn hospital in 2022; after more than two months at the hospital, the patient was diagnosed with a C. auris infection. The patient had not been screened for C. auris upon admission because the hospital's screening protocols at the time classified the patient as low-risk. After diagnosis, the hospital conducted a full outbreak investigation, testing 118 people who were directly exposed to the patient or shared equipment with the patient. The investigation identified eight additional patients who tested positive for C. auris.

Given the time and resources required for the investigation, the hospital's Infection Prevention and Control Department adjusted its recommended C. auris screening protocols for new patients, expanding them to include all admissions from skilled nursing facilities or patients who had been in such a facility within the past month. After using the new protocols for one year, they compared outcomes for that year to the nine-month period prior to the screening change.

The study spanned 591 patients who were screened for C. auris; that includes 34 patients with the old screening approach and 557 patients screened under the expanded protocol. The positivity rate increased from 1.8% to 2.4%, indicating that more cases were being detected with the broader screening approach. More specifically, the old criteria would have flagged 53 patients as high-risk, and nine of them would have tested positive for C. auris. The expanded protocol added 538 more patients, five of whom tested positive but would not have been identified through the old screening protocol. Ultimately, the new protocol identified eight cases that would have been missed, representing a significant threat to other patients and the hospital environment. Test results were returned within three days, allowing the team to identify cases quickly and implement appropriate isolation, contact, and disinfection precautions to prevent outbreaks.

"Early identification of patients colonized with C. auris allows us to protect other patients and helps to prevent the spread of the pathogen to the hospital environment and shared equipment," said Scott Lorin, MD, president of Mount Sinai Brooklyn and an author of the study. "Notably, we saw no spread of this infection from the eight patients identified by the expanded screening protocols who would have been missed by our prior protocol. When you consider how many other people they came into contact with during their hospital stays, that's a lot of patients kept safer by the implementation of broader screening. This expanded screening protocol has allowed us to detect Candida auris cases earlier, helping us prevent potential hospital outbreaks."

Additional details from the study include:

• The study was performed at an acute care hospital with 212 beds, where staff members have been caring for patients colonized with C. auris since the pathogen first emerged in New York City in 2016.
• The hospital's original screening framework called for testing patients with recent previous stays at nine specific skilled nursing facilities known to care for people with C. auris, of whom the highest-risk patients were considered those who were ventilator-dependent or admitted with a tracheostomy.
• Under the new screening guidelines, it was not practical for the hospital to isolate every patient while awaiting test results. Instead, the high-risk patients were isolated while the lower-risk patients (those from a skilled nursing facility but without a tracheostomy or ventilator) were treated using Standard Precautions until results were reported.

"This is a compelling demonstration of the value of broader screening for C. auris among patients admitted to hospitals after spending time at a skilled nursing facility," said Tania Bubb, PhD, RN, CIC, FAPIC, 2024 APIC president. "Expanded screening is an effective infection prevention practice that should be considered at all hospitals, particularly in areas where this pathogen has been circulating."

About APIC

Founded in 1972, the Association for Professionals in Infection Control and Epidemiology (APIC) is the leading association for infection preventionists and epidemiologists. With more than 15,000 members, APIC advances the science and practice of infection prevention and control. APIC carries out its mission through research, advocacy, and patient safety; education, credentialing, and certification; and fostering development of the infection prevention and control workforce of the future. Together with our members and partners, we are working toward a safer world through the prevention of infection. Join us and learn more at apic.org.

About AJIC

As the official peer-reviewed journal of APIC, The American Journal of Infection Control(AJIC) is the foremost resource on infection control, epidemiology, infectious diseases, quality management, occupational health, and disease prevention. Published by Elsevier, AJIC also publishes infection control guidelines from APIC and the CDC. AJIC is included in Index Medicus and CINAHL. Visit AJIC atajicjournal.org.

NOTES FOR EDITORS

"Analysis of an expanded admission screening protocol for Candida auris at a New York City hospital," by Aaron Cheng, Karen Marie Brody, Jordan Ehni, Zachary Gallate, Scott Lorin, Bernard Camins, and Waleed Javaid, was published online in AJICon October 31, 2024. DOI is: 10.1016/j.ajic.2024.08.027. Available at: https://doi.org/10.1016/j.ajic.2024.08.027

AUTHORS

Aaron Cheng, MPH, Mount Sinai Beth Israel and Mount Sinai Brooklyn

Karen Brody, MSN, RN, GERO-BC, CIC, Mount Sinai Beth Israel and Mount Sinai Brooklyn

Jordan Ehni, MPH, CIC, Mount Sinai Beth Israel and Mount Sinai Brooklyn

Zachary Gallate, MS, Icahn School of Medicine at Mount Sinai

Scott Lorin, MD, MBA, Icahn School of Medicine at Mount Sinai

Bernard Camins, MD, MS, Icahn School of Medicine at Mount Sinai

Waleed Javaid, MD, MBA, MS (corresponding author: [email protected]), Icahn School of Medicine at Mount Sinai

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Media contacts: Aaron Cohen, [email protected], 301-633-6773; Liz Garman, [email protected], 202-454-2604

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