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Candida auris is an emerging mul/drug-‐resistant (MDR) fungus associated with invasive infec/ons and high mortality. Since the first report of C. auris, isolated from a pa/ent’s ear canal in 2009, it has been implicated in mul/ple healthcare-‐associated outbreaks of candidemia. Between 2009–2016 cases of C. auris have been reported worldwide. This report describes the first 9 confirmed cases of C. auris in Central America, iden/fied in a hospital in Panama City, Panama, and highlights the challenges of accurate iden/fica/on and methods for suscep/bility tes/ng using current phenotypic systems, such as Vitek® 2 (bioMérieux) and Etest®.
INTRODUCTION
A total of 14 Isolates, from 9 pa/ents, that were ini/ally iden/fied as Candida haemulonii or Candida spp. by Vitek® 2 automated system (bioMérieux) at one of the largest acute care hospitals (>500 beds) in Panama City, Panama. Matrix-‐assisted laser desorp/on/ioniza/on (MALDI-‐TOF) was performed by Vitek® MS (bioMérieux) in Panama city. Results were confirmed at CDC (Atlanta, USA) by Microflex® (Bruker) systems, and by DNA sequencing the D1/D2 region of the 28S. We compared results of an/fungal suscep/bility obtained by Vitek® 2 automated system for fluconazole and echinocandins, specifically anidulafungin and caspofungin; results were compared to CLSI broth microdilu/on using custom-‐made frozen panels (TREK Diagnos/c Systems, Thermo Scien/fic. Oakwood Village, OH, United States). Amphotericin B MICs obtained by Vitek® 2 were compared to results from Etest®. All medical chart abstrac/on was performed by a local clinician. Local and CDC ethics commiiee reviewed and determined that it met criteria for non-‐research public health response.
METHODS
Fourteen isolates originally iden/fied as Candida haemulonii (n=13) or Candida spp. (n=1), recovered from 9 pa/ents during July–October 2016 (Figure 2), were confirmed as C. auris by both Vitek® MS and Microflex® MALDI-‐TOF plamorms and by sequencing of the D1/D2 region. Six (67%) of nine pa/ents were male, and the median age was 48 years (range: 20–78). The median length of admission was 89 days (range: 30–208), and the median /me from admission to first posi/ve culture was 34 days (range: 21–136). All pa/ents were admiied to intensive care units (ICUs). Median /me from posi/ve culture date to death in those who died was 45 days (range: 8–72) (Table 1). Treatment and outcome informa/on was available for all 9 pa/ents (Table 2).
RESULTS
CONCLUSIONS These reports of culture posi/ve C. auris represent the first documented emergence of the organism in Central America, coming shortly aper reports from Venezuela and Colombia. The in-‐hospital mortality rate among the Panama pa/ents was high (78%), likely related to the pa/ents’ underlying reasons for admission to the ICU. Given the large size of the hospital, clustering of cases by /me, and paucity of C. auris iden/fied elsewhere in the hospital, healthcare-‐associated transmission appears likely. Regional awareness of this organism among laboratorians and clinicians is cri/cal for prompt iden/fica/on with MALDI-‐TOF or DNA sequencing, improved outcomes for pa/ents, and early implementa/on of infec/on preven/on and control measures. We highlight the importance of correct iden/fica/on and suscep/bility tes/ng for this species of Candida.
REFERENCES 1. CDC C. auris Clinical Alert to U.S. Healthcare Facili/es Available at:
hips://www.cdc.gov/fungal/diseases/candidiasis/candida-‐auris-‐alert.html
2. Calvo B, et al. J Infect. 2016;73:369-‐374. 3. Vallabhaneni S, et al. MMWR Morb Mortal Wkly Rep. 2016;65:1234-‐1237. 4. Lockhart SR, et al. Clin Infect Dis. 2017;64:134-‐140. 5. Kathuria S, et al. Clin Microbiol. 2015;53:1823-‐1830.
ACKNOWLEDGEMENTS Anastasia Litvintseva, Reina Turcios-‐Ruiz, Loren Cadena, Alex Bandea and Colleen Lysen at CDC. Itza Barahona de Mosca, Lourdes Garcia and Felicia Tulloch at Ministerio de Salud de Panama. Rubén Ramos at the Ins/tuto Conmemora/vo Gorgas de Estudios de la Salud, Panama. Angel Cedeño, Medical Director of Hospital Santo Tomas and Gloria Acevedo and her team at the group of Infec/on control and preven/on commiiee of Hospital Santo Tomas.
Ana Belen Araúz1, Diego H Caceres2,3, Erika San/ago1, Paige Armstrong2,4, Susan Arosemena 1, Carolina Ramos1, Andres Espinosa-‐Bode2, Jovanna Borace1, Lizbeth Hayer 5, Israel Cedeño 5, Brendan R Jackson2, Nestor Sosa 6, Elizabeth L Berkow2, Shawn R Lockhart2, Amalia Rodriguez-‐French1 and Tom Chiller2
1 Hospital Santo Tomas, Panama City, Panama. 2 Centers for Disease Control and Preven/on, Atlanta, GA, United States of America. 3 ORISE, Oak Ridge, Tennessee, United States of America. 4 Epidemic Intelligence Service. Atlanta, GA, United States of America. 5 Ministerio de Salud de Panama, Panama City, Panama. 6 Ins/tuto Conmemora/vo Gorgas de Estudios de la Salud, Panama City, Panama
First nine cases of Candida auris infecDon Reported in Central America: Importance of acurate diagnosis and suscepDbility tesDng
anabelenarauz@gmail.com
Table 2. CharacterisDcs and treatment received by the 9 paDents with C. auris isolated from culture, Panama
Figure 2. Epidemiological curve of culture-‐posiDve C. auris infecDons during epidemiological weeks 26 to 44 of 2016
Table 1. CharacterisDcs of 9 paDents with C. auris posiDve cultures
Thirteen of the 14 isolates were available for fluconazole suscep/bility tes/ng by the Vitek® 2 system and broth microdilu/on. Twelve (92%) isolates were resistant to fluconazole by Vitek® 2, and 10 (77%) were resistant by broth microdilu/on. The fluconazole MIC50 was 32 µg/mL by Vitek® 2 and was 64 µg/mL by broth microdilu/on. Twelve isolates were available for amphotericin B suscep/bility tes/ng; all were iden/fied as resistant by the Vitek® 2 system, but only 1 (8%) by Etest®. The MIC50 for amphotericin B was 6 µg/mL by Vitek® 2 and 0.38 µg/mL by Etest®(figure 1 A and B). All isolates (n=13) were suscep/ble to anidulafungin and caspofungin by Vitek® 2 and broth microdilu/on.
Candida auris is an emerging mul/drug-‐resistant (MDR) fungus associated with invasive infec/ons and high mortality. This report describes the first 9 cases of C. auris in Central America in a hospital in Panama City, Panama, and highlights the challenges of accurate iden/fica/on and methods for suscep/bility tes/ng.
ABSTRACT
Variable n (%)
Mean age in years (range) 53 (42-‐78)
Sex (male) 6 (67)
Crude mortality 7 (78%)
30 days aper C. auris isolated 2 (22%)
Comorbidi/es prior to hospitaliza/on
Diabetes 1 (11)
Hematologic malignancy 0 (0)
Solid organ transplant 0 (0)
Hospitaliza/on
ICU 9 (100)
Mechanical ven/la/on 9 (100)
Total parenteral nutri/on 0 (0)
Central venous catheter present in the 7 days prior to C. auris posi/ve culture 9 (100)
Urinary catheter present in the 7 days preceding culture 9 (100)
Surgical procedure in 90 days prior to C. auris posi/ve culture* 9 (100)
An/fungal received in 90 days prior to C. auris posi/ve culture 7 (78)
An/bio/c received prior to C. auris posi/ve culture 9 (100)
* including tracheostomy
# Reason for Admission Source of C. auris Culture AnDfungal Received a]er posiDve for C. auris
Time from Admission to posiDve culture (days)
Outcome (at discharge)
1 Polytrauma, blunt injury 2 posi/ve urine cultures Voriconazole 48 Deceased
2 Sepsis 2 posi/ve urine cultures Voriconazole 49 Deceased
3 Urosepsis Urine Fluconazole 34 Deceased
4 Polytrauma, blunt injury 3 posi/ve urine cultures Voriconazole 22 Alive
5 Penetra/ng trauma to chest and abdomen Blood, Pleural Fluid Anidulafungin 21 Alive
6 Ischemic cerebrovascular accident Urine Fluconazole 22 Deceased
7 Second degree burn (50% body surface area) Urine Voriconazole 29 Deceased
8 Craniopharyngioma Central Venus Catheter /p Fluconazole 136 Deceased
9 Hypertensive emergency Urine Voriconazole 39 Deceased
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