The laboratory investigation, management, and infection prevention and control of Candida auris: a narrative review to inform the 2024 national guidance update in England.

The emergent fungal pathogen Candida auris is increasingly recognised as an important cause of healthcare-associated infections globally. It is highly transmissible, adaptable, and persistent, resulting in an organism with significant outbreak potential that risks devastating consequences. Progress in the ability to identify C. auris in clinical specimens is encouraging, but laboratory diagnostic capacity and surveillance systems are lacking in many countries. Intrinsic resistance to commonly used antifungals, combined with the ability to rapidly acquire resistance to therapy, substantially restricts treatment options and novel agents are desperately needed. Despite this, outbreaks can be interrupted, and mortality avoided or minimised, through the application of rigorous infection prevention and control measures with an increasing evidence base. This review provides an update on epidemiology, the impact of the COVID-19 pandemic, risk factors, identification and typing, resistance profiles, treatment, detection of colonisation, and infection prevention and control measures for C. auris. This review has informed a planned 2024 update to the United Kingdom Health Security Agency (UKHSA) guidance on the laboratory investigation, management, and infection prevention and control of Candida auris. A multidisciplinary response is needed to control C. auris transmission in a healthcare setting and should emphasise outbreak preparedness and response, rapid contact tracing and isolation or cohorting of patients and staff, strict hand hygiene and other infection prevention and control measures, dedicated or single-use equipment, appropriate disinfection, and effective communication concerning patient transfers and discharge.

Hospital outbreak of carbapenem-resistant Enterobacterales associated with a blaOXA-48 plasmid carried mostly by Escherichia coli ST399.

A hospital outbreak of carbapenem-resistant Enterobacterales was detected by routine surveillance. Whole genome sequencing and subsequent analysis revealed a conserved promiscuous blaOXA-48 carrying plasmid as the defining factor within this outbreak. Four different species of Enterobacterales were involved in the outbreak. Escherichia coli ST399 accounted for 35 of all the 55 isolates. Comparative genomics analysis using publicly available E. coli ST399 genomes showed that the outbreak E. coli ST399 isolates formed a unique clade. We developed a mathematical model of pOXA-48-like plasmid transmission between host lineages and used it to estimate its conjugation rate, giving a lower bound of 0.23 conjugation events per lineage per year. Our analysis suggests that co-evolution between the pOXA-48-like plasmid and E. coli ST399 could have played a role in the outbreak. This is the first study to report carbapenem-resistant E. coli ST399 carrying blaOXA-48 as the main cause of a plasmid-borne outbreak within a hospital setting. Our findings suggest complementary roles for both plasmid conjugation and clonal expansion in the emergence of this outbreak.

Screening for Candida auris in patients admitted to eight intensive care units in England, 2017 to 2018.

BackgroundCandida auris is an emerging multidrug-resistant fungal pathogen associated with bloodstream, wound and other infections, especially in critically ill patients. C. auris carriage is persistent and is difficult to eradicate from the hospital environment.AimWe aimed to pilot admission screening for C. auris in intensive care units (ICUs) in England to estimate prevalence in the ICU population and to inform public health guidance.MethodsBetween May 2017 and April 2018, we screened admissions to eight adult ICUs in hospitals with no previous cases of C. auris, in three major cities. Swabs were taken from the nose, throat, axilla, groin, perineum, rectum and catheter urine, then cultured and identified using matrix-assisted laser desorption/ionisation time-of-flight mass spectrometry (MALDI-TOF MS). Patient records were linked to routine ICU data to describe and compare the demographic and health indicators of the screened cohort with a national cohort of ICU patients admitted between 2016 and 2017.ResultsAll C. auris screens for 921 adults from 998 admissions were negative. The upper confidence limit of the pooled prevalence across all sites was 0.4%. Comparison of the screened cohort with the national cohort showed it was broadly similar to the national cohort with respect to demographics and co-morbidities.ConclusionThese findings imply that C. auris colonisation among patients admitted to ICUs in England is currently rare. We would not currently recommend widespread screening for C. auris in ICUs in England. Hospitals should continue to screen high-risk individuals based on local risk assessment.

Understanding why healthcare workers refuse the flu vaccine.

BACKGROUND: Vaccination is one of the most effective interventions used to reduce infections. Nonetheless, concerns and misconceptions about vaccines have resulted in an increased rate of refusal of vaccination among healthcare workers (HCWs) and within the general population. AIM/ OBJECTIVE: To understand the factors that underlie vaccination-refusal. METHODS: A questionnaire was given to the HCWs in the inpatient area of an acute London hospital during May 2019. The sample was one of convenience, i.e. the wards where the principle investigator covered. All staff were approached: 306 in total completed the questionnaire. FINDINGS/RESULTS: In total, 212 (69.28%) healthcare professionals had the flu vaccine during the 2018-2019 campaign, 94 (30.62%) did not have the flu vaccine and 37 (39.36%) of the HCWs that did not receive the flu vaccine reported they had previously a bad reaction following administration of the vaccine. DISCUSSION: This report will provide the Trust and other healthcare settings with information integrating the disconnection between misconceptions and vaccination knowledge, which may inform practical interventions to address the challenges of vaccination in future campaigns. Increasing HCWs' knowledge of flu vaccine side effects could address this and may increase rates of vaccination compliance.

Role of the Hospital Environment in Norovirus Containment.

Norovirus is an important cause of gastroenteritis in healthcare settings; these infections occur frequently, are highly contagious, and can be difficult to control. Norovirus outbreaks were investigated during a 3-month enhanced surveillance period from 1 February to 30 April 2015 in 6 London, United Kingdom, hospitals (coded A-E). During this surveillance period, 1379 stool samples were tested for the presence of norovirus. Of these, 129 (9.4%) demonstrated the presence of norovirus RNA. Two of these hospitals (A and D) reported 0 outbreaks, 2 (hospitals C and F) reported 1 outbreak, 1 hospital (B) reported 2 outbreaks, and hospital E reported 16 norovirus outbreaks during this period. The hospital with a newer infrastructure (B), which reported 2 norovirus outbreaks, demonstrated that 7 bed-days had been lost over the 3-month period, compared with 512 bed-days lost by the hospital with an older, Nightingale-style infrastructure (E). Control measures included isolation, hand hygiene, environmental cleaning, and rapid diagnostic testing. Our data suggest that outbreak control is more difficult to achieve in a hospital with Nightingale-style wards and limited isolation facilities.