Lab Matters Winter 2020 - Page 20

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 • • • • 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 APHL.org