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Hata DJ, Humphries R, Lockhart SR. Candida auris: An Emerging Yeast Pathogen Posing Distinct Challenges for Laboratory Diagnostics, Treatment, and Infection Prevention. Arch Pathol Lab Med 2019; 144:107-114. [PMID: 31169997 DOI: 10.5858/arpa.2018-0508-ra] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT.— Candida auris is an emerging yeast species that was first described in 2009. This ascomycetous yeast is notable for resistance to azole antifungal agents, for environmental persistence, and for its ability to contaminate health care environments, resulting in patient colonization and nosocomial infections. OBJECTIVE.— To review the state of current knowledge addressing challenges in the accurate identification of C auris in the diagnostic microbiology laboratory, including application of phenotypic, proteomic, and genomic methodologies; characteristics that may predispose the human host to acquiring C auris; transmission; clinical presentations; treatment modalities; environmental decontamination; and infection prevention in health care settings. DATA SOURCES.— The PubMed search engine was used to access peer-reviewed literature published from 2009 to 2019. CONCLUSIONS.— The rapid emergence of C auris has presented unique challenges for the areas of laboratory diagnostics and infection prevention and in options for antifungal treatment, which are limited. The current lack of established antifungal susceptibility test breakpoints complicates therapeutic decision making. Enhanced awareness of this pathogen is essential to monitor outbreaks and to reduce the risk of spread within health care environments.
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Affiliation(s)
- D Jane Hata
- From the Department of Laboratory Medicine and Pathology, Mayo Clinic, Jacksonville, Florida (Dr Hata); Accelerate Diagnostics, Tucson, Arizona (Dr Humphries); and the Mycotic Diseases Branch, Centers for Disease Control, Atlanta, Georgia (Dr Lockhart)
| | - Romney Humphries
- From the Department of Laboratory Medicine and Pathology, Mayo Clinic, Jacksonville, Florida (Dr Hata); Accelerate Diagnostics, Tucson, Arizona (Dr Humphries); and the Mycotic Diseases Branch, Centers for Disease Control, Atlanta, Georgia (Dr Lockhart)
| | - Shawn R Lockhart
- From the Department of Laboratory Medicine and Pathology, Mayo Clinic, Jacksonville, Florida (Dr Hata); Accelerate Diagnostics, Tucson, Arizona (Dr Humphries); and the Mycotic Diseases Branch, Centers for Disease Control, Atlanta, Georgia (Dr Lockhart)
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Abstract
PURPOSE OF REVIEW To give an update on the recent emergence of Candida auris. RECENT FINDINGS C. auris is a pathogen, that evades present therapeutic options, that is highly virulent, causes disease in all types of patients, and spreads easily in the environment and among patients, thereby posing an imminent threat to our patients. The fact that C. auris, in addition, is more resilient to environmental disinfection and frequently misclassified during microbiological diagnostics only heightens its potential as a 'perfect villain.' SUMMARY Healthcare institutions, especially hospitals, need to ensure that their diagnostic and infection control policies to handle C. auris are in place.
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Weber DJ, Sickbert-Bennett EE, Kanamori H, Rutala WA. New and emerging infectious diseases (Ebola, Middle Eastern respiratory syndrome coronavirus, carbapenem-resistant Enterobacteriaceae, Candida auris): Focus on environmental survival and germicide susceptibility. Am J Infect Control 2019; 47S:A29-A38. [PMID: 31146847 PMCID: PMC7132701 DOI: 10.1016/j.ajic.2019.03.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Abstract
PURPOSE OF REVIEW Candida auris has recently emerged as a pathogen with the potential for nosocomial transmission and outbreaks. The aim of this review is to summarize the global dissemination of this pathogen, characterize patient and facility characteristics associated with infection and outbreaks, and outline evidence to support interventions to prevent of transmission in the healthcare setting. RECENT FINDINGS C. auris has emerged separately in four clades, with international spread within a decade of its first identification and report. Acquisition and infection have predominantly been identified as healthcare-associated events. The presence of invasive devices, intensive care, and broad-spectrum antibiotic and antifungal use may be important risk factors for the development of infection due to C. auris. Nosocomial transmission is likely associated with colonization density and suboptimal infection prevention practices. The optimal strategy for reducing transmission from the environment requires further study. Candida auris is a recently emerging fungal pathogen that may cause nosocomial infections and outbreaks. Based on observed transmission patterns and interventions, key prevention measures outlined in the review include case finding and surveillance, hand hygiene, and environmental disinfection.
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Affiliation(s)
- Graham M Snyder
- Department of Infection Prevention and Control, University of Pittsburgh Medical Center, 3601 5th Avenue, Falk Medical Building, Suite 150, Pittsburgh, PA, 15213, USA.
| | - Sharon B Wright
- Division of Infection Control/Hospital Epidemiology, Silverman Institute of Health Care Quality and Safety, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Mailstop SL-435, Boston, MA, 02215, USA
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de Groot T, Chowdhary A, Meis JF, Voss A. Killing of Candida auris by UV-C: Importance of exposure time and distance. Mycoses 2019; 62:408-412. [PMID: 30748018 PMCID: PMC6850319 DOI: 10.1111/myc.12903] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 02/05/2019] [Indexed: 11/28/2022]
Abstract
Background Candida auris is a globally emerging yeast, causing severe infections in patients with underlying diseases. This yeast is responsible for several outbreaks within healthcare facilities, where it can be found on hospital surfaces and patient care devices. Spread from these fomites may be prevented by improving the decontamination of hospital surfaces. UV‐C decontamination may constitute an effective adjunct to routine room cleaning. Objectives Our aim was to investigate the effect of different UV‐C exposure times and distance in killing C auris, using strains from different countries. Methods Candida auris was seeded on glass slides and exposed to UV‐C for 5, 10, 20 and 30 minutes at 2 and 4 m. Results A maximal effect of C auris killing was found after 30 minutes of UV‐C exposure at 2 m. With half the time or twice the distance, the efficacy strongly diminished to ~10 and ~50 fold, respectively. At suboptimal exposure times and distances, the C auris strains from Japan/Korea were more sensitive to UV‐C killing than C auris strains originating from Venezuela, Spain and India. Conclusions Altogether, UV‐C exposure times and distance are the most critical parameters to kill C auris, while strain variations of C auris also determine UV‐C efficacy. Future studies should aim to determine the effect and place of UV‐C on surface decontamination in hospital setting.
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Affiliation(s)
- Theun de Groot
- Department of Medical Microbiology and Infectious Diseases, Canisius Wilhelmina Hospital (CWZ), Nijmegen, The Netherlands
| | - Anuradha Chowdhary
- Department of Medical Mycology, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
| | - Jacques F Meis
- Department of Medical Microbiology and Infectious Diseases, Canisius Wilhelmina Hospital (CWZ), Nijmegen, The Netherlands.,Centre of Expertise in Mycology Radboudumc/CWZ, Nijmegen, The Netherlands.,Department of Medical Microbiology, Radboudumc, Nijmegen, The Netherlands
| | - Andreas Voss
- Department of Medical Microbiology and Infectious Diseases, Canisius Wilhelmina Hospital (CWZ), Nijmegen, The Netherlands.,Centre of Expertise in Mycology Radboudumc/CWZ, Nijmegen, The Netherlands.,Department of Medical Microbiology, Radboudumc, Nijmegen, The Netherlands
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Ledwoch K, Maillard JY. Candida auris Dry Surface Biofilm (DSB) for Disinfectant Efficacy Testing. MATERIALS (BASEL, SWITZERLAND) 2018; 12:E18. [PMID: 30577589 PMCID: PMC6337396 DOI: 10.3390/ma12010018] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 12/12/2018] [Accepted: 12/14/2018] [Indexed: 11/20/2022]
Abstract
Candida auris is an emerging pathogen that needs to be controlled effectively due to its association with a high mortality rate. The presence of biofilms on dry surfaces has been shown to be widespread in healthcare settings. We produced a C. auris dry surface biofilm (DSB) on stainless steel surfaces following sequential hydration and desiccation cycles for 12 days. The ASTM2967-15 was used to measure the reduction in viability of 12 commercially wipe-based disinfectants and sodium hypochlorite (1000 ppm) against C. auris DSB. We also evaluated C. auris transferability and biofilm regrowth post-treatment. A peracetic acid (3500 ppm) product and two chlorine-based products (1000 ppm available chlorine) were successful in reducing C. auris viability and delaying DSB regrowth. However, 50% of the products tested failed to decrease C. auris viability, 58% failed to prevent its transferability, and 75% did not delay biofilm regrowth. Using three different parameters to measure product efficacy provided a practical evaluation of product effectiveness against C. auris DSB. Although log10 reduction in viability is traditionally measured, transferability is an important factor to consider from an infection control and prevention point of view as it allows for determination of whether the surface is safe to touch by patients and hospital staff post-treatment.
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Affiliation(s)
- Katarzyna Ledwoch
- School of Pharmacy and Pharmaceutical Sciences, Cardiff University, Cardiff CF10 3NB, UK.
| | - Jean-Yves Maillard
- School of Pharmacy and Pharmaceutical Sciences, Cardiff University, Cardiff CF10 3NB, UK.
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Arikan-Akdagli S, Ghannoum M, Meis JF. Antifungal Resistance: Specific Focus on Multidrug Resistance in Candida auris and Secondary Azole Resistance in Aspergillus fumigatus. J Fungi (Basel) 2018; 4:jof4040129. [PMID: 30563053 PMCID: PMC6308933 DOI: 10.3390/jof4040129] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 11/29/2018] [Accepted: 12/03/2018] [Indexed: 12/20/2022] Open
Abstract
Antifungal resistance is a topic of concern, particularly for specific fungal species and drugs. Among these are the multidrug-resistant Candida auris and azole-resistant Aspergillus fumigatus. While the knowledge on molecular mechanisms of resistance is now accumulating, further data are also available for the clinical implications and the extent of correlation of in vitro resistance to clinical outcomes. This review article summarizes the epidemiology of C. auris infections, animal models focusing on the activity of novel antifungal compounds in C. auris infections, virulence factors, and the mechanisms of antifungal resistance for this multi-resistant Candida species. Regarding A. fumigatus, the significance of azoles in the treatment of A. fumigatus infections, reference methods available for the detection of resistance in vitro, molecular mechanisms of secondary azole resistance, routes of acquisition, and clinical implications of in vitro resistance are covered to provide guidance for the current status of azole resistance in A. fumigatus.
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Affiliation(s)
- Sevtap Arikan-Akdagli
- Department of Medical Microbiology, Mycology Laboratory, Hacettepe University Medical School, TR-06100 Ankara, Turkey.
| | - Mahmoud Ghannoum
- Center for Medical Mycology, Department of Dermatology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH 44106, USA.
| | - Jacques F Meis
- Department of Medical Microbiology and Infectious Diseases, Canisius Wilhelmina Hospital (CWZ), 6532 Nijmegen, The Netherlands.
- Centre of Expertise in Mycology Radboudumc/CWZ, 6532 Nijmegen, The Netherlands.
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de Cássia Orlandi Sardi J, Silva DR, Soares Mendes-Giannini MJ, Rosalen PL. Candida auris: Epidemiology, risk factors, virulence, resistance, and therapeutic options. Microb Pathog 2018; 125:116-121. [DOI: 10.1016/j.micpath.2018.09.014] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 09/01/2018] [Accepted: 09/07/2018] [Indexed: 10/28/2022]
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Kean R, McKloud E, Townsend EM, Sherry L, Delaney C, Jones BL, Williams C, Ramage G. The comparative efficacy of antiseptics against Candida auris biofilms. Int J Antimicrob Agents 2018; 52:673-677. [DOI: 10.1016/j.ijantimicag.2018.05.007] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 03/26/2018] [Accepted: 05/08/2018] [Indexed: 10/28/2022]
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Antifungal activity of octenidine dihydrochloride and ultraviolet-C light against multidrug-resistant Candida auris. J Hosp Infect 2018; 102:120-124. [PMID: 30261239 DOI: 10.1016/j.jhin.2018.09.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 09/11/2018] [Indexed: 11/20/2022]
Abstract
Outbreaks due to multidrug-resistant Candida auris have emerged as a large threat to modern medicine. Since skin colonization and environmental contamination have been identified as a precursor for outbreaks, we evaluated the antifungal activity of ultraviolet-C light using mercury vapour lamp with a peak emission of 254 ± 2 nm and octenidine dihydrochloride against C. auris clinical isolates. Octenidine dihydrochloride was found effective at significantly lower concentrations (0.00005-0.0004%) than those currently used in the clinical setting (0.05-0.1%). Scanning electron microscopy images show destruction of the organism within 6 h of exposure to 0.0005% octenidine dihydrochloride. Ultraviolet-C light could kill all C. auris with 15 min exposure.
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Nowbakht C, Ostrosky-Zeichner L. Candida auris: What We Need to Know in Healthcare Settings. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2018. [DOI: 10.1007/s40506-018-0168-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Ku TSN, Walraven CJ, Lee SA. Candida auris: Disinfectants and Implications for Infection Control. Front Microbiol 2018; 9:726. [PMID: 29706945 PMCID: PMC5906573 DOI: 10.3389/fmicb.2018.00726] [Citation(s) in RCA: 96] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 03/28/2018] [Indexed: 01/18/2023] Open
Abstract
Candida auris is a rapidly emerging pathogen and is able to cause severe infections with high mortality rates. It is frequently misidentified in most clinical laboratories, thus requiring more specialized identification techniques. Furthermore, several clinical isolates have been found to be multidrug resistant and there is evidence of nosocomial transmission in outbreak fashion. Appropriate infection control measures will play a major role in controlling the management and spread of this pathogen. Unfortunately, there are very few data available on the effectiveness of disinfectants against C. auris. Chlorine-based products appear to be the most effective for environmental surface disinfection. Other disinfectants, although less effective than chlorine-based products, may have a role as adjunctive disinfectants. A cleaning protocol will also need to be established as the use of disinfectants alone may not be sufficient for maximal decontamination of patient care areas. Furthermore, there are fewer data on the effectiveness of antiseptics against C. auris for patient decolonization and hand hygiene for healthcare personnel. Chlorhexidine gluconate has shown some efficacy in in vitro studies but there are reports of patients with persistent colonization despite twice daily body washes with this disinfectant. Hand hygiene using soap and water, with or without chlorhexidine gluconate, may require the subsequent use of alcohol-based hand sanitizer for maximal disinfection. Further studies will be needed to validate the currently studied disinfectants for use in real-world settings.
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Affiliation(s)
- Tsun S N Ku
- Section of Infectious Disease, New Mexico VA Health Care System, Albuquerque, NM, United States.,Division of Infectious Diseases, Department of Internal Medicine, University of New Mexico Health Science Center, Albuquerque, NM, United States
| | - Carla J Walraven
- College of Pharmacy, University of New Mexico Health Science Center, Albuquerque, NM, United States
| | - Samuel A Lee
- Section of Infectious Disease, New Mexico VA Health Care System, Albuquerque, NM, United States.,Division of Infectious Diseases, Department of Internal Medicine, University of New Mexico Health Science Center, Albuquerque, NM, United States
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Kean R, Sherry L, Townsend E, McKloud E, Short B, Akinbobola A, Mackay W, Williams C, Jones B, Ramage G. Surface disinfection challenges for Candida auris: an in-vitro study. J Hosp Infect 2018; 98:433-436. [DOI: 10.1016/j.jhin.2017.11.015] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Accepted: 11/26/2017] [Indexed: 10/18/2022]
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Bougnoux ME, Brun S, Zahar JR. Healthcare-associated fungal outbreaks: New and uncommon species, New molecular tools for investigation and prevention. Antimicrob Resist Infect Control 2018; 7:45. [PMID: 29599969 PMCID: PMC5870726 DOI: 10.1186/s13756-018-0338-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 03/21/2018] [Indexed: 11/10/2022] Open
Abstract
Outbreaks of healthcare-associated fungal infections have repeatedly been described over recent years, often caused by new or uncommon species. Candida auris, a recently described multidrug-resistant yeast species, is certainly the most worrisome species having caused several severe healthcare outbreaks of invasive infections, on four continents. Also, large nosocomial outbreaks due to uncommon fungal species such as Exserohilum rostratum and Sarocladium kiliense, were both linked to contamination of medical products, however the source of another outbreak, caused by Saprochaete clavata, remains unresolved. Furthermore, these outbreaks identified new populations under threat in addition to those commonly at risk for invasive fungal infections, such as immunosuppressed and intensive care unit patients. All of these outbreaks have highlighted the usefulness of a high level of awareness, rapid diagnostic methods, and new molecular typing tools such as Whole Genome Sequencing (WGS), prompt investigation and aggressive interventions, including notification of public health agencies. This review summarizes the epidemiological and clinical data of the majority of healthcare-associated outbreaks reported over the last 6 years caused by uncommon or new fungal pathogens, as well as the contribution of WGS as support to investigate the source of infection and the most frequent control measures used.
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Affiliation(s)
- Marie-Elisabeth Bougnoux
- 1Unité de Parasitologie-Mycologie, Service de Microbiologie clinique, Hôpital Necker Enfants-Malades, Assistance Publique - Hôpitaux de Paris (APHP), Paris, France.,2Université Paris Descartes, Sorbonne Paris-Cité, Paris, France.,3Département Mycologie, Institut Pasteur, Unité Biologie et Pathogénicité Fongiques, Paris, France
| | - Sophie Brun
- 4Service de Parasitologie-Mycologie, Hôpital Avicenne, Groupe Hospitalier Paris-Seine-Saint-Denis, Assistance Publique - Hôpitaux de Paris (APHP), Bobigny, France.,5Université Paris 13, Bobigny, France
| | - Jean-Ralph Zahar
- 6Département de microbiologie clinique, unité de contrôle et de prévention du risque infectieux, Hôpital Avicenne, Groupe Hospitalier Paris-Seine-Saint-Denis, Assistance Publique - Hôpitaux de Paris (APHP), Bobigny, France.,7IAME, UMR 1137, Université Paris 13, Sorbonne Paris Cité, Paris, France
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Abstract
Candida auris has emerged globally as a multidrug-resistant health care-associated fungal pathogen. Recent reports highlight ongoing challenges due to organism misidentification, high rates of antifungal drug resistance, and significant patient mortality. The predilection for transmission within and between health care facilities possibly promoted by virulence factors that facilitate skin colonization and environmental persistence is unique among Candida species. This minireview details the global emergence of C. auris and discusses issues relevant to clinical microbiology laboratories, hospital infection control, and antimicrobial stewardship efforts.
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Jeffery-Smith A, Taori SK, Schelenz S, Jeffery K, Johnson EM, Borman A, Manuel R, Brown CS. Candida auris: a Review of the Literature. Clin Microbiol Rev 2018; 31:e00029-17. [PMID: 29142078 PMCID: PMC5740969 DOI: 10.1128/cmr.00029-17] [Citation(s) in RCA: 306] [Impact Index Per Article: 51.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
The emerging pathogen Candida auris has been associated with nosocomial outbreaks on five continents. Genetic analysis indicates the simultaneous emergence of separate clades of this organism in different geographical locations. Invasive infection and colonization have been detected predominantly in patients in high-dependency settings and have garnered attention due to variable antifungal resistance profiles and transmission within units instituting a range of infection prevention and control measures. Issues with the identification of C. auris using both phenotypic and molecular techniques have raised concerns about detecting the true scale of the problem. This review considers the literature available on C. auris and highlights the key unknowns, which will provide direction for further work in this field.
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Affiliation(s)
- Anna Jeffery-Smith
- Public Health England, United Kingdom
- Barts Health NHS Trust, London, United Kingdom
| | - Surabhi K Taori
- King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Silke Schelenz
- Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
| | - Katie Jeffery
- Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | | | | | | | - Colin S Brown
- Public Health England, United Kingdom
- Royal Free London NHS Foundation Trust, London, United Kingdom
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McCarthy MW, Walsh TJ. Containment strategies to address the expanding threat of multidrug-resistant Candida auris. Expert Rev Anti Infect Ther 2017; 15:1095-1099. [PMID: 29110544 DOI: 10.1080/14787210.2017.1402678] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Candida auris is an emerging multidrug resistant human yeast pathogen associated with nosocomial transmission and high mortality. The organism can be a challenge to diagnose, may be even more difficult to treat, and continues to pose an expanding threat to patients. Areas covered: Our medical center and others in the surrounding area have seen a concerning rise in confirmed cases of C. auris infection and substantial resources have been dedicated to containment measures. We draw on our in vitro and in vivo work with this organism to examine the most effective ways to curb the current outbreak. Expert commentary: We explore novel strategies to halt the spread C. auris, including enhanced molecular diagnostics, novel therapeutics, and epidemiologic studies to determine risk factors for infection and transmission.
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Affiliation(s)
- Matthew William McCarthy
- a Weill Cornell Medical College, Assistant Attending Physician, Division of General Internal Medicine , New York-Presbyterian Hospital , New York , NY , USA.,b Transplantation-Oncology Infectious Diseases Program, Chief, Medical Mycology Research Laboratory, Pediatrics, and Microbiology & Immunology , Weill Cornell Medical Center, Henry Schueler Foundation Scholar, Sharpe Family Foundation Scholar in Pediatric Infectious Diseases , New York , NY , USA
| | - Thomas J Walsh
- a Weill Cornell Medical College, Assistant Attending Physician, Division of General Internal Medicine , New York-Presbyterian Hospital , New York , NY , USA.,b Transplantation-Oncology Infectious Diseases Program, Chief, Medical Mycology Research Laboratory, Pediatrics, and Microbiology & Immunology , Weill Cornell Medical Center, Henry Schueler Foundation Scholar, Sharpe Family Foundation Scholar in Pediatric Infectious Diseases , New York , NY , USA
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