Candida Auris

candida auris

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Candida Auris  – An Introduction

Candida auris is a human fungal pathogen associated with severe invasive infections seen largely in hospitals, nursing homes and other health care settings. The most concerning issue is that Candida auris is associated with a high mortality rate due to this pathogen being a multidrug resistant fungus that has been reported in some recent cases to be resistant to all drugs. Cases are increasing as time goes by and medical experts are becoming increasingly concerned about this fungus.

What You Will Learn About Candida Auris

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Newer Multidrug Resistant Organism

As bacteria have become more resistant we have increased our use of antibiotic drugs as well as antibiotic cleaning chemicals. As we have increasingly used more antibiotics we naturally saw more fungal infections, and as we saw more fungal infections we used more antifungal drugs and antifungal cleaning agents. As we used more antifungals we saw more resistant candida species. Obviously, we are selecting for organisms that are resitsent to antibiotics and antifungals. This is not a sustainable response to bacteria and fungi. Let's take a close look at Candida auris to understand this situation.

Multidrug resistant organisms are on the rise including fungal infections. We are now getting reports of people carrying or infected with a strain of Candida yeast called Candida auris that is resistant to all major classes of antifungal drugs. This human pathogen is associated with severe invasive infections with high mortality rates ranging from 35 to 72% according to data from various areas of the world.

The medical director of infection prevention in Salem Oregon (USA) where a small recent outbereak took place said,  “With the COVID-19 pandemic, we have seen a rise in multi-drug resistant organisms around the world and nationwide and Salem is not immune”. The fact that this species of Candida is on the rise in hospitals, and other health care facilities is not a surprise since it is spread both from person to person as well as from contact with surfaces in the environment. With the use of so many antibiotic/antifungal medications, and additional use of antibacterial, antifungal cleaning agents used in hospitals and long-term care homes, it is not surprising that this fungus is becoming resistant to the antifungal chemicals used to kill it both in the body as well as on environmental surfaces. I would in fact expect to find more, and more pathogens becoming resistant to antimicrobials in the future as they survive by figuring out how to evade these drugs and cleaning agents. These pathogens learn to quickly alter their genetic makeup, and those who change enough become resistant to that chemical. Those that learn to become resistant are the ones that reproduce, and make more of themselves. As time goes by the very chemicals meant to erradicate them are the chemicals that increase their resistance. We need to rethink our approach as a society to these contagious infections.

What is odd about this specific illness, is that Candida species have all been thought to be commensals (a commensal is an organism that is in, or on a host that gets benefit from the host, but does not harm or benefit it’s host.) Candida auris which was first found in 2009 is the first Candida species found to commonly be a pathogen and unfortunately it is a pathogen that has according to the CDC killed 30-60% of those in the USA infected with it.

Candida Auris Is Currently Spread In Hospitals And Long Term Health Care Facilities

Some diseases are known to be more commonly spread in hospitals or health care facilities rather than in the general community. This is due to the environment in the hospital being more conducive to growing and spreading these infections. These pathogens are often drug resistant due to the reckless use of antibiotics, the constant use of chemicals to clean up surfaces in the health care facilities, as well as to clean medical instruments. This tends to breed pathogens which are resistant to antibiotics, antifungals and cleaning agents. Often these pathogens learn to use biofilms to protect themselves and they are then hard to eradicate. Candida auris is one of the Candida species known to create biofilm. The full story on C. auris and its resistance has not yet been elucidated, but reports of echinocandin (an antifungal drug) or pan-resistant C. auris cases in the USA are increasing. Multiple outbreaks have been identified in people with overlapping healthcare exposures who have not had previous antifungal treatment. This suggests transmission of resistant strains.

Whereas most of the Candida speices that cause health issues are species that were living in the body previously as commensals, this is nto the case with C. auris. It is more likely that this was in the environmnet of the hospital and ends up taking up residence in a patient that comes in for treatment of a wound, or they received some type of invasive procuedure such as a venapuncture for taking blood or an incision or intravenous line, and they pick up  the organism from the environment. It is not a threat to the general population, but is a threat to anyone that is in the hospital or in a nursing home.

Being Immunocompromised In The Hospital

The first line of immune defense is the barrier function of our skin which keeps pathogens on the outside of our body. The first thing done in hospital is to puncture the skin to put an IV in, which makes the individual immunocompromised although in a minor manner. If getting drugs that make them more immune deficient such as the current use of dexamethasone for COVID-19, that is another protective barrier taken down.

There are many elderly patients in the hospital and they often have a decreased immune system simply due to age.

Other immunocompromised people are in the hospital such as people getting organ transplants, those on chemotherapy for cancer, those on drugs for Autoimmune disease or other issues. Some dieseases such as diabetes open a person up to being more likely to get and suffer from infectious disease.

Candida auris

COVID-19 And The Response To COVID-19 Has Made This Fungus More Virulent

The response to COVID-19 in hospitals provided the perfect situation for this fungus to become more virulant and pathogenic.

Doctors in some countries have reported a rapid rise of drug-resistant C. auris in hospitals where COVID-19 patients are treated. Indeed cases in the USA have increased since the pandemic. Some of the possible reasons for the spread is as follows.

  • The steroid dexamethasone used in hospitals to treat severely ill COVID-19 patients suppresses their immunity to other infections. In addition, broad-spectrum antibiotics kill bacteria that live in the gut, and on the skin that usually compete with fungi for living space. Without the normal skin and gut flora, Candida is able to have a party.
  • Medical equipment that punctures the skin or is inserted into a body cavity such as a catheter can allow C. auris to invade the bloodstream and urinary tract.
  • There is also evidence that the Sars-CoV-2 virus damages the mucousal lining of the intestine, which provides the fungus another entry point to the bloodstream.
  • Disinfection practices may have bred more resistant organisms.
  • Changes in infection control practices such as reusing glowns, gloves and other items that are usually thrown out with each use probably added to the spread of infectious disease including C. auris.
  • Screening for C. auris colonization at healthcare facilities has been limited as attention is being paid to COVID-19 and other issues are side lined.
  • COVID-19 patients in the hopsital are often elderly who are already immune compromised or those patients who have other illnesses making them also more susceptible to C. auris.

History of Candida Auris

Candida auris was first identified in 2009 from a patient's ear canal in Japan. Collections of Candida strains have found that the earliest known strain of C. auris was found in 1996 in South Korea. It is considered an emerging pathogen by the Center of Disease Control (CDC) because of the increasing recognition in many countries since it was first recognized. At the time of writing this, the CDC identified 30 countries that have reported cases of C. auris. The interesting thing about this species is that genome sequencing from various countries has identified that C. auris emerged independently in multiple countries at around the same time.

Candida auris started in the eastern part of the USA and has slowly spread across the continent. 

Candida auris is the first multidrug-resistent species of yeast ever identified. It has been known spread between patients in the hospital and can cause serous bloodstream infection. It can unfortunately survive over long periods of time on hospital surfaces.

The CDC’s website says Candida auris illness became a reportable illness in 2018, but not all states are reporting it yet. The reported clinical cases as of August in 2021 was 1161 in the USA. In addition, targeted screening has found C. auris in  3,043 paitents colonized with C. auris. Due to the lack of complete reporting and poor screening, these numbers are probably much lower than the true cases and colinization. Those who are designated as colonized means they test positive for the illness, but do not have any symptoms. This is not considered an infection, it is considered a colinization. Colinization has been noted for many pathogens. For instance, many people carry Staph. bacteria. The CDC claims 33% of people carry Staph. aureus bacteria in their nose and 2% carry MRSA in their nose. We don't know how many might be carrying C. auris. Additional data on colinization is below.

Why The Concern About Candida Auris

  • Candida auris spreads rapidly
  • High mortality rates
  • It is frequently resistant to multiple antifungal drugs commonly used to treat Candida
  • It is difficult to identify with standard laboratory methods, and is commonly misidentified as other less problematic types of Candida species. Misidentification may lead to inappropriate management or even ignoring it.
  • Normal lab methods used to identify fungus are not accurate enough to ensure species identification of Candida auris. Specialized testing methods are needed to correctly identify Candida auris.
  • Due to misidentification, there are probably more cases of it and more people carrying it than is currently known.
  • It has caused outbreaks in healthcare settings. For this reason, it is important to quickly identify  C. auris in a hospitalized patient, so the healthcare facilities can take special precautions to stop its spread.
  • Infections have been found in all ages from the young to the elderly.
  • Candida auris is able to grow at 107 F making it more immune to fevers.
  • Candida auris is able to survive on human skin, and environmental surfaces for several weeks, and can even tolerate being exposed to some commonly used disinfectants, explaining it’s ability to persist in the hospital environment.

Problems Identifying Candida Auris

Candida auris is commonly misidentified as a variety of other Candida species that includes the following:

  1. C. haemulonii
  2. C. duobushaemulonii
  3. C. sake
  4. C. catenulata
  5. C. famata
  6. C. guilliermondii
  7. C. lusitaniae
  8. C. parapsilosis
  9. Rhodoturula lugtinis

When these species show up, we should consider that these species of Candida may have been misidentified and additional testing should be undertaken to make sure they are not really C. auris.

Types Of Infections Caused By Candidas Auris

  • Wound infections
  • Ear infections
  • Bloodstream infections

Candida auris has been identified from many body sites including the bloodstream, urine, respiratory tract, biliary fluid, wounds, and external ear canal, but it is unknown if it causes infections anywhere besides wound infections, ear infections and bloodstream infections.

How Does Candida Auris Spread

  • It is spread through contact with contaminated surfaces in the hospital or other health care settings.
  • Candida auris can be on health care equipment surfaces.
  • It can spread from person to person.
  • Our skin acts as a barrier to infection so anyone coming into a hospital with a wound or who has their skin penetrated by an IV etc. will be more likely to get this or other infections.

Who Is At Risk For Invasive Candida auris

Not enough is known about risk factors currently, but the following are thought to be risk factors.

  • People who are already sick
  • Patients who have been hospitalized for a long time
  • Patients with wounds
  • Patients who have had recent surgeries
  • Patients who have a central venous catheter
  • Patients with lines or tubes entering body
  • Patients who have previously received broad spectrum antibiotics or antifungal medications
  • Patients who are immunocompromised
  • Specifically people with neutropenia
  • Patients with diabetes
  • Individuals who have spent time in nursing homes and had lines and tubes in their body such as breathing, or feeding tubes, or catheters.
  • People with other serious health conditions are those that are most likely to die from C. auris

Methods Being Used To Prevent Candia Auris  Infections In Hopsitals

  • Risk assessment of patient population
  • Universal infection prevention practicies
  • Specific infection prevention practices
  • Contact precautions
  • Personal protective equipment
  • Cleaning and disinfecting equipment appropriately
  • Using an EPA chemical with antifungal claim (there is already resistance to some of these chemicals)
  • UV light for fighting fungal infections

If you have a family member or close contact with C. auris, you need to be sure to wash your hands before and after contact with them. If you are visiting a family member or friend in the hospital with C. auris, you can ask for a gown and gloves before going into their room. That gown and gloves needs to be put into appropriate bins before you leave the room. They should be given a private room by the hospital to decrease the spread of this organism. If you are admitting a friend or family member to the hospital and they have  C. auris, or they are a carrier, or if they stayed in a health care facility previously where C. auris was present, you need to notifit the medical staff at admission.

Who Should Be Screened For Candida Auris Colinization

The CDC has asked facilities to screen patients for C. auris colinization to identify those with colinization and implement infection prevention and control measures when found. This is who they suggest should be screened:

  • Patients who have had an overnight stay in a healthcare facility outside the United States, especially if in a country with documented C. auris cases.
  • Especially consider if the individual also has infection or colonization with carbapenease-producing Gram-negative bacteria which have been observed to co-colonize with C. auris. I would again point out that the USA is also one of these countries with documented C. auris cases, so I don’t know why our hospitals and health facilities are not included in screening folks, especially in the states known to have C. auris as listed above.
  • Close healthcare contacts of patients with a newly identified infection or colonization. Remember, this is an illness that is contracted in hospitals and other healthcare facilities.  A number of factors should be considered when deciding who should be screened that has had contact with a patient with C. auris.
    • Roommates at healthcare facilities, including nursing homes, where the index patient resided in the previous month. Ideally, identify and screen roommates of the index patient even if they were discharged from the facility.
    • Patients who require higher levels of care (e.g., mechanical ventilation) and who overlapped on the ward or unit with the index patient for 3 or more days, as these patients are also at substantial risk for colonization.
  • Patients with newly identified C. auris infection or colonization might have been colonized for months before detection of the organism. Therefore, it is also important to consider the patient’s prior healthcare exposures and contacts when devising a screening strategy.

Laboratories do not usually determine the Candida species from non-sterile sites as the presence of Candida in these sites is often due to colinization rather than an infection. However,the CDC says C. auris is important to identify even from a non-sterile body site because presence of C. auris in any body site can represent wider colonization, posing a risk for transmission and requiring implementation of infection control precautions. The CDC says species-level identification should be considered in certain circumstances, including:

  • When clinically indicated in the care of a patient.
  • When a case of C. auris infection or colonization has been detected in a facility or unit, in order to detect additional patients colonized. Species identification when Candida is found in non-sterile sites can be implemented for at least one month until no evidence exists of C. auris transmission.
  • When a patient has had an overnight stay in a healthcare facility outside the United States in the previous one year, especially if in a country with documented C. auris transmission. Colonization for longer than a year has been identified among some C. auris patients; therefore hospitals might also consider determining the species for Candida isolated from patients with more remote exposure to healthcare abroad.

I am not sure why hospitals in other countries known to have C. auris are identified seperately from the USA, as the USA is one of those same countries known to have C. auris cases in healthcare units, and therefore anyone staying in any healthcare facility in the USA in the previous year should also have species-level ID considered, especially in the states where C. auris has been found. The only reason I can assume this is not undertaken as it would cost an incredible amount of money and currently with the lack of hospital staff, there is not enough staff to actually do this.

How Screening Is Implemented

Testing for C. auris colonization screening is available through CDC’s AR Lab Network. The AR Lab Network performs this testing free of charge, although this testing may require coordination through the healthcare-associated infection (HAI) program of your state public health department (view state HAI contacts).

Screening for C. auris colonization is accomplished using a composite swab of the patient’s bilateral axilla and groin. Available data suggest that these sites are the most common and consistent sites of colonization. Although patients have been colonized with C. auris in the nose, mouth, external ear canals, urine, wounds, and rectum, these sites are usually less sensitive for colonization screening.

When the screening identifies someone with colonization, infection control precautions should be used the same as if they had C. aruis infection. It is also important to note that patients who become colonized with C. auris are at risk of developing invasive infections from this organism. Invasive infections can develop at any point after patients become colonized. Additional measures should be taken to help prevent invasive C. auris infection once patients become colonized with C. auris. Appropriate care of medical devices, surgical procedures and antibiotic stewardship must be stressed as described in detail at this CDC website:

Additional guidance on screening is available in the Interim Guidance for a Health Response to Contain Novel or Targeted Multidrug-resistant Organisms pdf icon

For CDC details and updates on surveillance and screening from the CDC, go to their website here.

Colonization Details

Candida has in the past been considered to be a harmless commensal that can turn into a pathogen under certain conditions. Candida auris usually causes superficial infections, but may cause more significant infections in immunocompromised patients. Finding colonies of Candida species in the digestive tract, vaginally or on other skins surfaces is considered a colinization and normal unless there are symptoms. For instance in healthy women, without symptoms, vaginal yeast colonization is considered a normal situation and does not need treatment. The difference between commensal yeast and colinization compared to a Candidal infection does not have a clear cut definition and the clinician must rely on asking questions that will help them identify if the person has symptoms or not. Better testing looking for invasive forms of Candida which are hyphal forms would be helpful and I would like to see this become standard practice. Candida albicans has been studied a lot and it has been found that the form that is commensal is what is called the yeast form. To get to a hyphal form, it  transforms from yeast, to pseudo-hyphal, then from pseudo-hyphal to hyphal forms. This could be used to identify a safe commensal state, the state of changing to a more aggressive form and finally the aggressive hyphal form. Due to Candida largely being ignored by mainstream medicine, this type of lab test is not commonly available.

We know that some people are found to be colonized by bacteria, viruses, or fungi that does not bother them, while others can be severely affected by the same pathogen. Why do some people when infected with a pathogen have more severe infections than other people? This is something that alternative practitioners focus on. We know that an individual’s overall health is important to their ability to withstand any disease. We also know that their immune system is key in this process. During the COVID-19 pandemic this has become common knowledge as the CDC has identified many health conditions and risk factors that make people more prone to experiencing severe COVID-19. However, this is true with most infectious disease processes. As practitioners, we can help people who are more prone to succumbing to pathogenic organisms zone in on the factors that can lead to their being more susceptible to illness. Additionally, we can focus on how the individual can decrease their susceptibility to infection, and help them become more able to decrease the severity of the disease should they become ill.

Candida species has not generally been thought of as pathogens in the past by mainstream medicine. Mainstream medicine has realized it could become invasive in hospital settings where there is extreme use of antibiotics, but rather hospital practitioners have always associated it with severely immunocompromised individuals even though we know Candida species creates a variety of infections on the skin and in the digestive tract. Candida all too often has been considered a natural part of the intestinal flora and skin, although it has been known to cause health conditions with some of the more common being:

  • Diaper rash
  • Heat rash in skin folds
  • Oral thrush
  • Jock Itch
  • Vulvavaginal candidiasis
  • Vaginal candadiasis

Now mainstream practitioners are taking note of Candida. When asked about the increase in drug resistant Candida auris, one physician named Dr. Kathleen Casey, clinical professor of medicine at Robert Wood Johnson Medical School, Rutgers University said, “Its been naive that we weren’t worried about a more resistant fungal pathogen.”

I would entirely agree with her.

Treatment

Consultation with an infectious disease specialist is highly recommended when caring for patients with C. auris infection.

Even after treatment for invasive infections, patients generally remain colonized with C. auris for long periods, and perhaps indefinitely. Therefore, all recommended infection control measures should be followed during and after treatment for C. auris infection.

Antifungal susceptibility testing should be performed for ALL clinical C. auris cases to guide therapy. This link will take you to a CDC site where susceptibility testing is discussed along with the current antifungal drugs being used.

Specific CDC guidelines can be found for treatment and management here. This includes  information for adults and children.

The CDC does not recommend treatment of C. auris identified from noninvasive sites (such as respiratory tract, urine, and skin colonization) when there is no evidence of infection. This is similar to recommendations for other Candida species. Treatment is generally only indicated if clinical disease is present. However, infection control measures should be used for all patients with C. auris, regardless of the source of specimen.

Alternative practitioners have been treating Candidal infections for years in patients. This has been necessary due to the heavy use of antibiotics. Some of these treatments should be immediately studied for possible use in C. auris infections. We do have many preventative methods as well as treatments for Candida species in general. They could be considered in addition to the drugs used, unless  contraindicated for a specific individual. Naturopaths or funcitonal medicine practitioners should be consulted by hospitals wanting to enhance the survival of their patients.  Additionally, the simple action of supporting the immune system will help an individual keep all pathogens, including Candida species better under control. I would add here though, that not everyone is able to enhance their immune system safely as they may have an organ transplant, autoimmune disease being treated with immune suppressive medications, or other reasons that this can't always be undertaken except in well defined parameters.

There are many research studies showing effectiveness of diet, supplements and herbs for prevention and treatment of Candida species, especially Candida albicans. However, similar research studies  on Candida auris are few and far between. There is a 2020 study showing  five herbal consitutents which were effective at inducing cell wall remodeling in both Candida albicans and Candida auris. These 5 herbal constituents were sodium houttuyfonate (from Houttuynia cordata), berberine (from many berberine containing species such as Berberis vulgaris, Mahonia aquifolium, Hydrasts canadensis, Xanthorhiza simplicissima, Phellodendron amurense, Coptis chinensis, and Tinospora cordifolia), palmatine (found in Phellodendron amurense, Coptis chinensis, Corydalis yanhusuo, Tinospora cordifolia, and Stephania yummanensis), jatrorrhizine (found in Enantia chlorantha) and cinnamaldehyde (from Cinnamomum spp.).

The Berberis and Mahonia plants that contain berberine often contain another consitutent called 5'-methoxyhydnocarpin-D (5'-MHC-D)  which has been found to decrease the ability of other Candidal species to resist some of the antifungal drugs that they have built up resistance to.   It seems to be a no-brainer that these Mahonia and Berberis plants might be useful to decrease the resistance of Candida auris to our current antifungal drugs in use. However, without research, we will never know about this. We also won't know how helpful whole antifungal plants or their constituets would be against this species of Candida without adequate research.

I would especially like to see studies on whole herbs as the Mahonia and Berberis herbs contain both berberine, which has been shown to be antifungal, as well as  the 5'-MHC-D which keeps the fungus from pumping the berberine and some drugs back out of the fungus by the use of multidrug efflux pumps. I do realize that this is a really big request, since no one wants to fund a study that does not end up with a product that can be patented. However, perhaps our society would like to fund it with our tax dollars. I usually have to look for such research from other countries as we are unlikely in the USA to fund research on whole herbs.

You can find a whole article on berberine and its known affect on other Candida species in this article.

 

Drugs Are In Route From A Class Of Compounds First Discovered In Mahogany Bark

Researchers found that C. auris was found to be sensitive to translation inhibition by rocaglates, a class of compounds first discovered in mahogany bark. The rocaglates inhibit translation initiation in C. auris, leading to activation of a cell death program that is characterized by features of both apoptosis, a common form of cell death, and autophagy, an alternative mode of cell death. However, I would mention that Candida albicans showed inherent resistance to the rocaglates, due to an amino acid variant in the drug-binding domain.

Candida And Alternative Practitioners

Naturopathic physicians and functional medicine physicians have looked at Candida a little differently than mainstream medicine. They also see Candida as a normal flora in the digestive tract, but they also realize it is an opportunistic pathogen that can be an issue in people other than the severely immunocompromised. An individual may be exposed to toxins that chronically lowers their immunity slightly, or they may have taken antibiotics or other drugs that disrupts their normal gut flora allowing the Candida to grow out of control. There are also diseases which are associated with overgrowth of Candida such as diabetes. Even pregnancy is associated with yeast infections.

Alternative practitioners have been watching their patients succumb to various types of yeast infections after use of  Candidal inducing drugs for years. We have advocated  use of antibiotics only when absolutely necessary to decrease resistance of bacterial organisms to these drugs, but also because antibiotics kill off the good gut flora that help keep Candida species from becoming pathogenic. It is the injudicious use of antibiotics that has largely drove us off this Candida auris cliff. However, in addition the continual use of antifungal chemicals in the hospitals, nursing homes and now even in peoples own homes is creating bigger, badder fungi as they become resistant to all these chemicals. Additionally, there are practitioners using antifungals more often than necessary just as antibiotics have been used. These three factors are most likely at the heart of creating this fungal superbug although there are additional factors. I expect to see more fungal and bacterial super bugs if we don't change our ways.

Considering A New Point Of View

Rather than trying to kill every bacteria, fungus and virus, we need to focus more on creating vibrant, healthy bodies, rather than creating chemicals to kill the bacteria, viruses, and fungi that are overtaking our frail bodies. This is something that has to be started young, although it can help at any age. It is something that has to include lifestyle factors, diet, herbs and needs to include mental, emotional and spiritual health.

We need to increase the use of nutrition, supplements and herbs in mainstream medicine, so we are not in need of antibiotic and antifungal drugs as often. This does not mean we can chuck the antibiotic and antifungal drugs. However, it does mean we greatly decrease our dependance on them. We also need to examine using natural methods to clean the environment, which could include the use of enzymes and herbs. Rather than focusing on making a product that can be patented and used to make a lot of money, we as a society should consider investing in research to study safe cleaning methods that are less likely to create superbugs. Perhaps we can consider finding a way to live in harmony with our microbial community.  We won't know if it is possible if we don't try.

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Posted in Candida, Health Conditions, Mold And Toxins, Mold Related Illness and tagged , , , , , , ,