INFECTIOUS DISEASES
AR Lab Network Supports
Response to Candida auris
Outbreak in California
By Cecilia B. Kretz, PhD, manager, Emerging and Zoonotic Infectious Diseases
Candida auris is an emerging multidrug
resistant fungal pathogen capable of
causing invasive disease, especially in
seriously ill people. First identified in 2009
in Japan, it has now spread around the
world causing persistent and difficult-
to-control outbreaks in hospital settings.
Historically, large outbreaks of C. auris
have been reported mostly in New York
City, Chicago and New Jersey. However,
2019 saw the pathogen spread to other
2019 Urgent Threats
Report
URGENT THREATS
•
•
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•
Carbapenem-resistant Acinetobacter
Candida auris
Clostridioides difficile
Carbapenem-resistant Enterobacteriaceae
(CRE)
• Drug-resistant Neisseria gonorrhoeae
SERIOUS THREATS
•
•
•
•
•
•
•
•
•
•
•
Drug-resistant Campylobacter
Drug-resistant Candida
ESBL-producing Enterobacteriaceae
Vancomycin-resistant Enterococci (VRE)
Multidrug-resistant Pseudomonas
aeruginosa
Drug-resistant nontyphoidal Salmonella
Drug-resistant Salmonella serotype Typhi
Drug-resistant Shigella
Methicillin-resistant Staphylococcus
aureus (MRSA)
Drug-resistant Streptococcus pneumoniae
Drug-resistant Tuberculosis
CONCERNING THREATS
• Erythromycin-Resistant Group A
Streptococcus
• Clindamycin-resistant Group B
Streptococcus
WATCH LIST
• Azole-resistant Aspergillus fumigatus
• Drug-resistant Mycoplasma genitalium
• Drug-resistant Bordetella pertussis
18
LAB MATTERS Winter 2020
areas in the US including a notable C. auris
outbreak in Orange County, California.
Standing Up Detection Systems
In February 2019, the Orange County
Public Health Laboratory (OCPHL)
received an isolate from a local reference
laboratory identified as Candida species
not albicans. OCPHL sent the isolate to
the California Department of Public
Health Microbial Diseases Laboratory
for confirmation that identified it as C.
auris. As a result, a point prevalent survey
(PPS) was initiated at the facility where
the patient resided, and the US Centers
for Disease Control and Prevention
(CDC) deployed an EpiAid team to
perform additional PPS at other facilities.
Investigating the outbreak at this scale
would not be possible without the
strength of the Antibiotic Resistance (AR)
Lab Network.
In the case of the Orange County
outbreak, OCPHL received collection kits
for the PPS from the AR Lab Network.
The kits were delivered to the healthcare
facilities by couriers, sometimes multiple
times per day, and swabs returned to
the lab were then shipped to different
regional laboratories. Once the swabs were
received, regional laboratories performed
molecular testing and culture to identify
the pathogen. Due to the large size of this
response, multiple regional laboratories
were engaged to meet the testing demand.
As of January 2020, 60 facilities conducted
PPS with 6,398 swabs sent to regional
laboratories. PPS is still ongoing.
Learning Where to Improve
Through Execution
Although logistically complex, the
Orange County response was ultimately
successful due to strong and frequent
communication and the flexibility of the
many entities involved. However, several
challenges were identified, primarily
The AR Lab Network was established in
2016 as a national initiative, with the goals
of detecting, characterizing, responding
and containing emerging threats from AR
pathogens. The Network includes public
health laboratories from all 50 states,
five cities and Puerto Rico. Seven public
health laboratories serve as regional labs
that provide enhanced testing capacity
and services to laboratories within their
region. The success of the AR Lab Network
requires collaboration across health care
facilities, clinical laboratories, state and
local PHLs, regional laboratories and CDC.
associated with slightly different
testing algorithms at various regional
laboratories. Regional laboratories may
have different specimen requisition
forms and shipping practices, as well
as different testing algorithms due to
differences in LIMS, individual laboratory
requirements and regional testing needs.
The Network is currently examining the
feasibility of additional standardization or
at least ensuring that differences between
regional laboratories are communicated at
the beginning of large-scale responses.
The emergence of Candida auris on a
global scale is worrisome. As public
health laboratories prepare to combat C.
auris, they should consider conducting
outreach to clinical laboratories in their
jurisdiction to understand their capacity
and to provide educational materials,
training and information concerning
communication challenges that can
occur when multiple jurisdictions and
entities are involved. The AR Lab Network
has increased laboratory capacity and
improved communication between public
health laboratories and epidemiologists
fostering new ways of thinking about
identifying, testing and responding to
emerging AR threats from local, regional
and global perspectives. n
PublicHealthLabs
@APHL
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