key: cord-0776736-ltwo2mf6 authors: Nobrega de Almeida, João; Brandão, Igor B.; Francisco, Elaine C.; de Almeida, Silvio Luis R.; de Oliveira Dias, Patrícia; Pereira, Felicidade M.; Santos Ferreira, Fábio; de Andrade, Thaisse Souza; de Miranda Costa, Magda M.; de Souza Jordão, Regiane T.; Meis, Jacques F.; Colombo, Arnaldo L. title: Axillary Digital Thermometers uplifted a multidrug‐susceptible Candida auris outbreak among COVID‐19 patients in Brazil date: 2021-06-07 journal: Mycoses DOI: 10.1111/myc.13320 sha: 2af7601c3d9b0f1834c0e19256a31205d5dfd477 doc_id: 776736 cord_uid: ltwo2mf6 OBJECTIVES: To describe the first outbreak of Candida auris in Brazil, including epidemiological, clinical and microbiological data. METHODS: After the first Candida auris‐colonised patient was diagnosed in a COVID‐19 ICU at a hospital in Salvador, Brazil, a multidisciplinary team conducted a local C. auris prevalence investigation. Screening cultures for C. auris were collected from patients, healthcare workers and inanimate surfaces. Risk factors for C. auris colonisation were evaluated, and the fungemia episodes that occurred after the investigation were also analysed and described. Antifungal susceptibility of the C. auris isolates was determined, and they were genotyped with microsatellite analysis. RESULTS: Among body swabs collected from 47 patients, eight (n = 8/47, 17%) samples from the axillae were positive for C. auris. Among samples collected from inanimate surfaces, digital thermometers had the highest rate of positive cultures (n = 8/47, 17%). Antifungal susceptibility testing showed MICs of 0.5 to 1 mg/L for AMB, 0.03 to 0.06 mg/L for voriconazole, 2 to 4 mg/L for fluconazole and 0.03 to 0.06 mg/L for anidulafungin. Microsatellite analysis revealed that all C. auris isolates belong to the South Asian clade (Clade I) and had different genotypes. In multivariate analysis, having a colonised digital thermometer was the only independent risk factor associated with C. auris colonisation. Three episodes of C. auris fungemia occurred after the investigation, with 30‐day attributable mortality of 33.3%. CONCLUSIONS: Emergence of C. auris in Salvador, Brazil, may be related to local C. auris clade I closely related genotypes. Contaminated axillary monitoring thermometers may facilitate the dissemination of C. auris reinforcing the concept that these reusable devices should be carefully cleaned with an effective disinfectant or replaced by other temperature monitoring methods. In the last decade, we have witnessed the emergence and worldwide nosocomial spread of the new human opportunistic pathogen Candida auris. 1, 2 Outbreaks of hospital-acquired infections and the potential of C. auris to develop multidrug resistance have alarmed the medical and scientific communities. 3 Previous C. auris-free hospitals now have this yeast among the leading agents of bloodstream infections. [4] [5] [6] During the ongoing COVID-19 pandemic, the overwhelmed intensive care units (ICUs) have been a fertile ground for the emergence and spread of C. auris. [7] [8] [9] Until end of 2020, C. auris was not reported in Brazil 10 but recently we reported the first two patients that had been hospitalised due to severe After being notified by the local hospital infection control team (HICT), the Brazilian Ministry of Health and the National Sanitary Surveillance Agency (NSSA) set in place a task force to map and control a possible outbreak. Based on published guidelines [12] [13] [14] and on previous reported experiences, [15] [16] [17] an intervention took place, including cohorting and collection of surveillance cultures of potential C. auris-colonised patients. Details about the cross-sectional investigation of the first outbreak of C. auris in Brazil and the fungemia episodes that occurred after the investigation are described. The outbreak took place in a 330-bed hospital in Salvador, Bahia, Brazil. The hospital has three intensive care units (ICUs) with a total of 66 beds for critically ill patients. The hospital has an additional 63 semi-intensive care unit (SICU) and 201 ward beds. In March 2020, when the SARS-CoV-2 pandemic began in Brazil, one of the three ICUs with 20 beds were allocated to patients with severe COVID-19. On December 2, 2020, the first Candida auris-colonised patient was diagnosed at the hospital. 11 The patient had spent 38 days at the COVID-19 ICU, and after a negative nasopharyngeal PCR for SARS-CoV-2, was transferred to one of the three SICU. The cross-sectional investigation took place on December 16, 2020. All patients were or had been hospitalised at the COVID-19 ICU, as well as their close contacts (defined as patients that were hospitalised at the same unit and attended by the same healthcare worker team) were considered potential C. auris-colonised patients and were investigated. Fungemia episodes that occurred after the investigation were also analysed. Since no invasive procedures were required for the investigation and due to the urgent sanitary relevance, the Brazilian Ministry of Health and the institutional review board waved patients' and healthcare workers' consent to carry on the study. Patient and healthcare worker anonymity was assured during this investigation. Candida auris screening cultures with sterile swabs (one per site, premoistened with sterile saline) were used to collect samples from the following sites of the suspected colonised patients: axillae, groins, ears, nostrils and pressure ulcers when present. Additionally, healthcare workers underwent a visual inspection of their hands, and skin or trophic nail lesions were also swabbed. After sampling, the swabs were immediately inoculated in 15-ml conical tubes (one swab per tube), containing Sabouraud dextrose broth (SDA) enriched with 10% NaCl, and shipped to the laboratory to be incubated at 40°C for 7 days. Tubes were checked every 24 h for yeast growth, and positive samples were plated on chromogenic agar (CHROMagar™ Candida, DIFCO) that were incubated for 24-48 h at 37°C. Samples were collected with 3M sponge-sticks (Fisher Scientific, Pittsburg, Pennsylvania) as recommended. 12, 18 The environment from the index case and from the potential C. auris-colonised with C. auris colonisation. Three episodes of C. auris fungemia occurred after the investigation, with 30-day attributable mortality of 33.3%. patients at the ICUs or SICUs had an initial visual inspection, and the high-touch inanimate sites were selected to be sampled (one sponge stick per site): bed rails; mechanical ventilators, vital signs monitors and intravenous infusion pumps (composite sample); reusable digital thermometers (inside plastic recipient on the wall); and tray tables. Additional areas in the vicinity of the patients, including faucets, sinks, computer keyboards (protected with plastic film) and mouse, ultrasound probes and hand sanitiser wall dispensers were also sampled. Immediately after sampling, the sponge-sticks were put into sterile plastic bags, sealed and shipped to the laboratory. In the laboratory, the sponge-sticks were inserted into 50-ml conical tubes (one sponge-sticks per tube) containing SDB with 10% NaCl and incubated at 40°C for 7 days. Tubes were checked every 24 h for yeast growth, and positive samples were plated on chromogenic agar (CHROMagar™ Candida) and incubated at 37°C for 24-48 h. Clinical cultures were collected from patients during sepsis investigation. Blood cultures were carried out with BacT/ALERT aerobic bottles (bioMérieux, Marcy-l'Etoile, France) and incubated in the automated BacT/ALERT 3D system (bioMérieux) at 35°C. Central venous catheter tip (CVC-tip) samples and positive blood culture samples were inoculated on blood sheep agar that were incubated for 24-48 h at 37°C. Urine cultures were plated on chromogenic medium for urinary samples and incubated 24-48 h at 37°C. Yeast colonies from blood cultures, CVC-tip or urinary samples were initially identified by the Vitek 2 system (YST cards, bioMérieux). Clinical isolates with C. auris identified by the Vitek 2 system (bioMérieux), and yeasts recovered from screening cultures were identified by MALDI-TOF mass spectrometry (VitekMS, bioMérieux, Marcyl'Etoile, France). Final species characterisation was carried out by ITS rDNA sequencing analysis. 19 All sequences were deposited and are available at GenBank (Supplementary Material, https://www.ncbi. nlm.nih.gov/genba nk/). The in vitro activity of amphotericin B (AMB, Sigma-Aldrich, Saint Louis, MO, USA), fluconazole (Sigma-Aldrich), voriconazole (Sigma-Aldrich) and anidulafungin (Sigma-Aldrich) against the C. auris isolates was evaluated by the CLSI broth microdilution reference method. 20 Plates were incubated at 37°C and minimal inhibitory concentrations (MICs) were read after 24 h. To investigate the clonality between the clinical and environmental C. auris isolates, microsatellite typing with four multiplex PCR reactions was (M2, M3-I, M3-II, M9) performed as previously described. 21 A selection of clinical and environmental Brazilian isolates, and representative strains from other countries were analysed. UPGMA dendrogram of short tandem repeats (STR) genotypes was constructed with the software BioNumerics, version 7.6.1 (Applied Maths NV-bioMérieux, Sint-Martens-Latem, Belgium). The investigators filled a form for all cases with clinical samples positive for C. auris and for all potentially colonised patients. The form required information regarding demographics; comorbidities and baseline diseases, including COVID-19 diagnosis; associated conditions including invasive medical procedures; and previous exposure to antimicrobials, corticosteroids or antifungals. These data were further combined with the screening cultures results, and the patients were than finally classified as C. auris colonised (case) or noncolonised (controls). Cases with missing clinical or microbiologic data were excluded. To describe the potential risk factors for C. auris colonisation, data comparisons between the colonised vs non-colonised patients were carried out with SPSS software v.22 (IBM, Armonk, NY, USA). Categorical variables were expressed as percentage and continuous variables as median ±standard deviation (SD). Differences between the groups were evaluated with Chi-squared test, Fisher's exact test or the Mann-Whitney U test. Variables associated with p values < .3 on univariate basis were introduced into the multivariate model. Two-tailed p values < .05 were considered statistically significant. To describe the bloodstream infection episodes, data regarding CVC removal, antifungal treatment, and 30-day outcomes were also collected. The doctor in charge of the patient was asked to classify the patient's death as attributable or non-attributable to the C. auris fungemia episode. (Table 2 ). In multivariate analysis, having a positive digital thermometer culture was the only independent risk factor associated with C. auris colonisation. Three patients had bloodstream infections by C. auris between December 12, 2020, and February 20, 2021 . All patients died in the 30-day follow up period after the infection. In one case, the death was attributed to the fungemia episode. Details about these three fungemia episodes are provided in Table 3 . The widespread presence of C. auris in the patient´s vicinities, in- 26, 27 Outbreaks of C. auris are usually associated with fluconazole resistance, with at least more than 10% of the isolates considered AMB resistant. 15, 17, 28, 29 In contrast, all forty-five strains we analysed had low AMB, fluconazole and anidulafungin MICs. We previously reported that the first strain had wildtype ERG11 and FKS1 DNA sequences. 11 Although not evaluated in this study, we assume that all isolates lack the ERG11 and FKS1 hotspot mutations due to the persistent low azole and anidulafungin MICs. These peculiar findings Data curation (lead); Formal analysis (lead); Investigation (lead) Validation (supporting) Writing-original draft (lead) Igor Brandão: Data curation (equal) Investigation (equal) Resources (equal) Supervision (equal); Writing-original draft (supporting) Writing-review & editing (equal) Data curation (lead); Formal analysis (equal) Supervision (equal) Silvio Luis Rodrigues: Data curation (equal) Investigation (equal) Validation (equal) Patrícia de Oliveira Dias: Data curation (equal) Investigation (equal) Project administration (supporting) Felicidade Pereira: Data curation (equal) Investigation (equal) Resources (equal) Fabio Ferreira: Investigation (equal) Supervision (equal) Validation (equal) Thaisse Andrade: Data curation (equal); Formal analysis (equal) Supervision (equal) Magda Miranda: Conceptualization (equal); Data curation (equal) Formal analysis (equal) Investigation (equal) Resources (equal) Supervision (equal) Regiane Jordão: Formal analysis (equal) Investigation (equal) Resources (equal) Supervision (equal) Writing-review & editing (equal) Meis: Data curation (equal); Formal analysis (equal) Investigation (equal) Resources (equal) Validation (equal) Arnaldo Lopes Colombo: Conceptualization (equal) Data curation (equal); Formal analysis (equal); Funding acquisition (lead); Investigation (equal) Resources (lead) Supervision (equal) Validation (lead) Writing-original draft (lead) Larissa Molina: Data curation (supporting) Soraia Lima: Data curation (supporting); Formal analysis (supporting) Supervision (supporting) Ricardo Lima: Data curation (supporting); Formal analysis (supporting) Investigation (supporting) Ismaiane Miranda: Data curation (supporting) Investigation (supporting) Data curation (supporting); Formal analysis (supporting) Investigation (supporting) Danniely Silva: Data curation (supporting) Investigation (supporting) Project administration (supporting); Validation (supporting) Data curation (supporting); Investigation (supporting) Laíse Ribeiro: Data curation (supporting) Antonio Carlos Bandeira: Formal analysis (supporting) Project administration (supporting) Talita Urpia: Data curation (supporting); Investigation (supporting) Formal analysis (supporting); Investigation (supporting) Resources (supporting) Supervision (supporting) Theun de Groot: Data curation (supporting); Formal analysis (supporting) Investigation (supporting) Methodology (supporting) All sequences were deposited and are available at GenBank (supplementary material Simultaneous emergence of multidrug-resistant Candida auris on 3 continents confirmed by whole-genome sequencing and epidemiological analyses Candida auris: a global fungal public health threat A Candida auris-the growing menace to global health Candida auris in South Africa Multidrug-resistant endemic clonal strain of Candida auris in India Candida auris candidaemia in an intensive care unit -prospective observational study to evaluate epidemiology, risk factors, and outcome Candida auris outbreak in a COVID-19 specialty care unit -Florida Outbreak of Candida auris infection in a COVID-19 hospital in Mexico Spread of carbapenem-resistant gram-negatives and Candida auris during the COVID-19 pandemic in critically Ill patients: one step back in antimicrobial stewardship? Microorganisms Brazil is so far free from Candida auris. Are we missing something? Emergence of Candida auris in Brazil in a COVID-19 intensive care unit Candida auris: a review of recommendations for detection and control in healthcare settings Control of Candida auris in healthcare institutions: Outcome of an International Society for Antimicrobial Chemotherapy expert meeting Gerência Geral de Tecnologia em Serviços de Saúde, Agência Nacional de Vigilância Sanitária. COMUNICADO DE RISCONo 01/2017-GVIMS/GGTES/ANVISA. Relatos de surtos de Candida auris em serviços de saúde da América Latina First hospital outbreak of the globally emerging Candida auris in a European hospital An outbreak due to Candida auris with prolonged colonisation and candidaemia in a tertiary care European hospital A Candida auris outbreak and its control in an intensive care setting Molecular epidemiology of Candida auris in Colombia reveals a highly related, countrywide colonization with regional patterns in Amphotericin B resistance Nuclear ribosomal internal transcribed spacer (ITS) region as a universal DNA barcode marker for Fungi Reference Method for Broth Dilution Antifungal Susceptibility Testing of Yeasts Development of Candida auris short tandem repeat typing and its application to a global collection of isolates Evaluation of nine surface disinfectants against Candida auris using a quantitative disk carrier method: EPA SOP-MB-35 Lee SA Candida auris: disinfectants and implications for infection control Candida auris in an intensive care setting Candida auris in healthcare facilities Multidrug-resistant candida auris infections in critically Ill coronavirus disease patients First Candida auris outbreak during a COVID-19 pandemic in a Tertiary Hospital-associated multicenter outbreak of emerging fungus Candida auris, Colombia Molecular epidemiology of Candida auris outbreak in a major secondary-care hospital in Kuwait Molecular epidemiological investigation of a nosocomial cluster of C auris: evidence of recent emergence in Italy and ease of transmission during the COVID-19 pandemic Molecular characterisation and clinical outcomes of Candida auris infection: singlecentre experience in Saudi Arabia A cluster of Candida auris blood stream infections in a Tertiary Care Hospital in Oman from 2016 to 2019 Candida auris in various hospitals across Kuwait and their susceptibility and molecular basis of resistance to antifungal drugs Multidrug-resistant Candida auris: an epidemiological review First report of Candida auris in America: clinical and microbiological aspects of 18 episodes of candidemia Isolation of Candida auris from 9 patients in Central America: importance of accurate diagnosis and susceptibility testing Talita Moreira Urpia Mara Rubia Gonçalves (Brazilian Health Regulatory Agency, Ministério da Saúde, Brasília, Brazil)