Implementation of a Survey to Assess Candida auris Laboratory Testing Capacity in Virginia

1. Implementation of a Survey to Assess Candida auris Laboratory Testing Capacity in Virginia Christina Martone, MPH Policy and Prevention Specialist Office of Epidemiology, Virginia Department of Health Coauthors: Shaina Bernard, PharmD, BCPS Carole Carter, MLS(ASCP)cm

2. Disclosure • The authors and contributors of this project have no conflicts of interest to disclose.

3. Background Candida auris • New York Times – April 2019 • New York Times – April 2019 • The Philadelphia Inquirer– May 2019 • U.S. News and World Report– April 2019 • CNN – April 2019 • New York Times – April 2019 • Newsweek– April 2019

4. Background Candida auris • Why is it such a problem? • C. auris spreads quickly • Hospitals nursing homes • Persists in the environment • List K

5. Background Background: Candida auris • https://www.cdc.gov/fungal/candida-auris/tracking-c-auris.html#world

6. Background Background: Candida auris • U.S. Map: Clinical cases of C. auris reported by U.S. states, as of April 30, 2019 • https://www.cdc.gov/fungal/candida-auris/tracking-c-auris.html#world

7. Background Candida auris Why is it such a problem? C. auris spreads quickly It can cause serious infections

8. Background Candida auris Why is it such a problem? C. auris spreads quickly It can cause serious infections It’s very difficult to treat

9. Background: Candida auris • Isolates from U.S. cases belong to all four C. auris clades as of August 2017 • Resistance • Based on limited data available, an echinocandin drug is recommended initial therapy for treatment of invasive C. auris infections • Virginia case is from the South Asian clade • Chow et. al., 2018

10. Background: Candida auris • Resistance • Resistance for isolates from the South Asian clade: • 3% • Echinocandin resistance • 93% • Fluconazole • resistance • 40% • Polyene • resistance • https://www.cdc.gov/fungal/candida-auris/c-auris-treatment.html

11. Background: Candida auris • Resistance • For isolates from all clades: • No defined susceptibility breakpoints, but CDC has recommended breakpoints • Based on: • Closely related Candida species • Expert opinion • https://www.cdc.gov/fungal/candida-auris/c-auris-antifungal.html

12. Background: Candida auris Why is it such a problem? C. auris spreads quickly It can cause serious infections It’s very difficult to treat Difficult to identify

13. Background: Candida auris CDC-recommended methods that can identify C. auris Bruker Biotyper MALDI-TOF: RUO libraries OR CA System library bioMérieux VITEK MS MALDI-TOF RUO library with Saramis Version 4.14 database and Saccharomycetaceae update 2) 1) 3)

14. Background: Candida auris C. auris is reportable in Virginia November 2018 Virginia laboratories must report and submit suspected or confirmed C. auris • ? • Virginia Reportable Disease List • VDH Interpretive Guidance for Reporting and Submitting Specimens

15. Background: Candida auris Table 1. Summary of common misidentifications based on the identification method used (adapted from CDC) *Vitek MS can confirm C. auris if you have the research use only library (Saramis Version 4.14 database and Saccharomycetaceae update); however, C. auris can be misidentified as C. haemulonii and should be sent to DCLS for identification/confirmation. ** Vitek 2 software version 8.01 contains identification algorithms for C. auris; however, misidentification has been reported for some clades (e.g., South African and East Asian). It is recommended to send isolates to DCLS for identification/confirmation until more data are available.

16. Objective • Identify which Virginia sentinel labs have the ability to correctly identify C. auris • Will help identify gaps in C. auris reporting and will aid in future case confirmation • Allow VDH and Division of Consolidated Laboratory Services (DCLS) to provide facility-specific information on reporting requirements • Understand burden of C. auris testing • What are Sentinel laboratories? • Laboratories capable of analyzing or referring samples that may contain agents of public health significance

17. Methods • Designed a survey in REDCap asking several questions about mycology capabilities: • Ability to identify certain non-albicans Candida species • Yeast identification methods • Ability to identify C. auris • DCLS emailed survey to all 49 sentinel laboratories • Survey completed from November 2018 to February 2019

18. Methods • When determining if a facility could identify C. auris, CDC recommendations at that time were used. • Vitek 2 YST Update • Still a possibility to misidentify C. auris Bruker Biotyper MALDI-TOF: RUO libraries OR CA System library bioMérieux VITEK MS MALDI-TOF RUO library with Saramis Version 4.14 database and Saccharomycetaceae update 2) 1) 3)

19. Results • 75% • (37/49) laboratories responded • 19.4% • 19.4% • 22.2% • 22.2% • 16.7%

20. Results • Number of sentinel laboratories that use certain yeast identification methods. (n=29*) • *Some laboratories selected more than one yeast ID method

21. Results • Number of sentinel laboratories who identified certain non-albicans Candida species. (n=29)

22. Results Number of laboratories that have the ability to identify C. auris using one of the three recommended methods, and the number who cannot identify C. auris. (n=29) • Number of Sentinel Laboratories Can correctly identify C. auris using one of the three recommended methods Cannot identify C. auris

23. Results Number of laboratories conducting antifungal susceptibility testing (AFST) either in house or through a reference laboratory. (n=29)

24. Results Number of laboratories testing certain antifungals. (n=16)

25. Summary • Surveillance • Know if C. auris isolate can be identified at sentinel laboratories • Reduce misidentification of C. auris • Investigation • CDC Containment Strategy for Novel or Targeted Multi-Drug Resistant Organisms! • Faster and more accurate investigations • https://www.cdc.gov/hai/containment/guidelines.html

26. Next Steps • VDH to provide tailored letters to laboratories: • Information on the recommended C. auris identification methods • Reminders to send commonly misidentified organisms to the DCLS

27. Limitations • Interpretation of survey questions • Labs could have updated systems; what we are presenting today may have changed from when the respondent answered

28. Antimicrobial Stewardship Implications • Methods use to identify C. auris vary greatly by facility • Find out methods used at your facility to identify C. auris • Know the types of organisms C. auriscan commonly be misidentified as • Assessing the appropriateness of antibiotics, especially antifungals, and discontinuing them when not needed may help prevent C. auris colonization and infection

29. Resources • VDH HAI High Sign C. auris Special Edition Newsletter • C. auris CDC website

30. Acknowledgements • Coauthors: • Shaina Bernard, PharmD, BCPS • Carole Carter, MLS(ASCP)cm • Healthcare-Associated Infections and Antimicrobial Resistance (HAI/AR) Team at VDH • DCLS • Sentinel Labs

31. Questions ??? Please email hai@vdh.virginia.gov with any questions.