An outbreak of multi-drug resistant Candida auris in a hospital neonatal intensive care unit (NICU) was linked to the use of multi-use thermometers, researchers found.
After adjustment, use of multi-patient skin axillary temperature monitoring, such as axial thermometers, was a significant independent predictor of C. auris infection (OR 6.80, 95% CI 2.96 to 15.64, P<0.001) -- albeit with a wide confidence interval, reported David Eyre, MD, of the University of Oxford in England, and colleagues.
Action Points
- Note that an epidemiologic study in a hospital NICU found that multi-use axillary thermometers were a possible nidus of C. auris infection.
- A separate observational study demonstrated that the "Infection Risk Scan" (IRIS) protocol was useful at improving markers such as hand hygiene.
- Note that this study was published as an abstract and presented at a conference. These data and conclusions should be considered to be preliminary until published in a peer-reviewed journal.
They presented the findings at the European Congress of Clinical Microbiology and Infectious Diseases (ECCMID), the annual meeting of the , held this year in Madrid.
The outbreak, described as one of the largest of C. auris to date, occurred in the Oxford University Hospitals' NICU. Following the outbreak, the authors said, an intensive patient and environmental screening program was instituted.
"Despite a bundle of infection-control interventions, the outbreak was only controlled following removal of the temperature probes," Eyre said in a statement. "This reinforces the need to carefully investigate the environment, and in particular, multi-use patient equipment, in any unexplained healthcare-associated outbreak."
The authors added that while C. auris was rarely detected in the general environment, it was cultured from "multi-patient use equipment" and "[visualized] on probe surfaces using scanning electron microscopy."
The researchers examined 70 patients who were colonized or infected with C. auris from February 2015 to August 2017. Median colonization duration was 39 days, and only seven patients developed an invasive infection. The authors noted that one patient died 229 days after the last invasive isolate. Moreover, there was no evidence that C. auris was linked to increased mortality (HR 1.21, 95% CI 0.64 to 2.29, P=0.55).
Sixty-six of these patients were admitted to the NICU prior to their diagnosis, and after adjusting for a variety of confounders, such as age, sex, and primary admission diagnosis. Of these, the thermometers were used in 57 of 66 cases admitted to the NICU prior to C. auris diagnosis, and in 122 of 361 controls.
In addition to multi-use thermometers, systemic fluconazole was used in three cases, and was also linked with a significantly increased risk of C. auris -- although with an extremely wide confidence interval (OR 10.2, 95% CI 1.64 to 63.5, P=0.01).
The authors noted that using C. albicans breakpoints, 79 of 79 isolates were resistant to fluconazole, 78 of 89 were resistant to voriconazole, and 66 of 73 were resistant to posaconazole.
Mixed Success for Infection Control Prevention Measures in Dutch Hospitals
In a reported at the meeting, Ina Willemsen, MD, of Amphia Hospital in Breda, The Netherlands, and colleagues examined a risk-assessment tool, the Infection Risk Scan (IRIS) that looks to prevent hospital-based infections and encourage appropriate use of antibiotics. The researchers found that while the IRIS system improved the personal hygiene of healthcare workers, improvements in hand hygiene compliance was unsustainable and appropriate use of antibiotics did not improve.
Willemsen et al conducted four consecutive assessments of hospitals using the IRIS tool over a period of 5 years, examining variables that also included:
- Environmental contamination using adenosine triphosphate (ATP) measurements
- Shortcomings in infection-control pre-conditions
- Appropriate use of indwelling medical devices
- Appropriate use of antibiotics
-
Transmission of Extended Spectrum Beta-Lactamase producing Enterobacteriaceae (ESBL-E) based on active screening swab
The authors noted that hand hygiene compliance improved in all five wards measured, with overall hand hygiene compliance increasing from 43% to 68%. But while the levels were reduced significantly, the improvements were not sustainable over time; notably, transmission of ESBL-E occurred only once, involving two patients, the authors said.
In a statement, Willemsen said that in the next 2 years, IRIS will be implemented in nine hospitals and in 40 nursing homes near the Dutch/Belgium border.
"Infection control needs user-friendly standardized instruments to measure the compliance to guidelines and to implement improvement actions," Willemsen said. "Repeated use of the IRIS makes it possible to monitor outcome and offers opportunities for targeted adjustment where needed. This results in a 'plan-do-check-act' quality cycle in infection control."
Disclosures
Eyre and colleagues disclosed no conflicts of interest.
Willemsen and colleagues disclosed no conflicts of interest.
Primary Source
European Society of Clinical Microbiology and Infectious Diseases
Eyre D, et al "Epidemiology and successful control of a Candida auris outbreak in a U.K. intensive care unit driven by multi-use patient monitoring equipment" ESCMID 2018; Abstract O0172.
Secondary Source
European Society of Clinical Microbiology and Infectious Diseases
Willemsen I, et al "The implementation of the infection risk scan (IRIS) in a Dutch hospital, resulting in standardization, transparency and substantial improvement" ESCMID 2018; Abstract O0173.