ISSN: 0973-7510

E-ISSN: 2581-690X

Mini Review | Open Access
Pallavi Ugemuge1, Sarita Ugemuge2 , Vaishnavi Mishra3 and Ashwini Tidake4
1Jawaharlal Nehru Medical College Sawangi (Meghe) Wardha, Datta Meghe Institute of Higher Education and Research (DU), Wardha, Maharashtra, India.
2Department of Microbiology, Datta Meghe MedicalCollege, Nagpur, Datta Meghe Institute of Higher Education and Research (DU), Wardha, Maharashtra, India.
3Department of Microbiology, Jawaharlal Nehru Medical College Sawangi (Meghe) Wardha, Datta Meghe Institute of Higher Education and Research (DU), Wardha, Maharashtra, India.
4Department of Microbiology, Datta Meghe Medical, College, Nagpur, Datta Meghe Institute of Higher Education and Research (DU), Wardha, Maharashtra, India.
Article Number: 8742 | © The Author(s). 2023
J Pure Appl Microbiol. 2023;17(4):2074-2079. https://doi.org/10.22207/JPAM.17.4.57
Received: 02 June 2023 | Accepted: 13 October 2023 | Published online: 02 December 2023
Issue online: December 2023
Abstract

Candida species are the most common cause of nosocomial fungal infections and the fourth most common cause of hospital-acquired illnesses. Fungal infection has been known to cause severe complications and even death in immunocompromised patients. With the rise in antibiotic resistance and an increase in invasive medical procedures, ICU patients are becoming more vulnerable to this infection. In order to fight this epidemic, it is essential to comprehend the causes, signs, and available treatments for Candida species. Candida auris is an exceptionally rare type of fungus that first surfaced in 2009 and poses a threat to global health. C auris-associated invasive infections have a greater mortality rate than infections caused by other Candida species. C. auris possesses a tendency to develop antifungal medication resistance, which would make therapy more challenging. While the precise cause of C. auris illnesses is uncertain, it is believed that healthcare workers can contract the illness by touching infected objects or surfaces. Medical professionals, nurses, and various other staff members all contribute significantly to preventing the transmission of C. auris infestations. Utilizing hand hygiene techniques like thorough hand washing or hand sanitizers that contain alcohol can significantly reduce the spread of fungi. It is crucial to provide healthcare workers with ongoing instruction in infection control, the proper use of antifungal medications, and the early identification of C. auris infections.

Keywords

Intensive Care Unit, Nurses, Hygiene, Antifungal, Invasive, Candida

Introduction

Infections with fungi have become a threat to human health on a worldwide scale. Around 1.7 billion people globally suffer from a fungus infection, with the majority of instances being mucosal and superficial skin infections.1 Candida species are the most common cause of nosocomial fungal infections and the fourth most common cause of hospital-acquired illnesses. Globally, around 400,000 bloodstream infections caused by Candida species occur each year, with death rates surpassing 40%.1,2 Fungal infection has been known to cause severe complications and even death in immunocompromised patients. With the rise in antibiotic resistance and an increase in invasive medical procedures, ICU patients are becoming more vulnerable to this infection.3 To fight this epidemic, it is essential to comprehend the causes, signs, and available treatments for Candida species.4 Immuno-compromised individuals, such as organ transplant recipients, those with hematologic malignancies, and HIV-positive individuals, are far more likely to develop systemic fungal infections. In the United States, the rate of nosocomial fungal infections has increased from 2 to 3.8 per 1000 discharges. The most prevalent isolate in ICU patients and contributing to 8–15% of nosocomial bloodstream infections was identified to be Candida spp.5 India is one of the developing nation with a diverse climate that supports a wide range of fungi illnesses. With the emergence of new fungal infections like Apophysomyces elegans, the prevalence of candidemia, systemic aspergillosis, cryptococcosis, and zygomycosis has substantially increased in India.6-8

C. auris in ICU patients
Candida is a type of yeast that is present in the human body and is usually harmless. However, when the immune system is compromised, Candida can cause infections, particularly in hospitalized patients.9 C. auris is an exceptionally rare type of fungus that first surfaced in 2009 and poses a threat to global health.10 It can cause severe infections in those who are susceptible and is resistant to several antifungal medications. C auris-associated invasive infections have a greater mortality rate than infections caused by other Candida species. C auris infections have a 30% to 72% crude fatality rate.11,12

Due to their compromised immune systems, prolonged hospitalizations, and the consumption of invasive healthcare tools such as catheterization and ventilators, ICU patients are more likely to get C. auris infections.13 Antibiotics with a broad spectrum of action can eliminate beneficial microbes, creating an environment where Candida can thrive. C. auris illnesses are often treated with antifungal drugs; however, due to a growing number of strains that are tolerant to antifungals therapy has become more challenging

Resistance to antifungal drugs by C. auris is well-documented and is one of the main drivers of its pathogenicity. C. auris exhibits consistently high fluconazole minimal inhibitory concentrations (MICs) and variable susceptibility to the other triazoles, echinocandins, and amphotericin B. Indeed, C. auris is the first Candida species to be classified as multidrug resistant (MDR). Of even greater concern is the emergence of C. auris strains that are pan-resistant, although novel antifungals such as ibrexafungerp and fosmanogepix have demonstrated in vitro and in vivo efficacy against C. auris.14

Causes of C. auris infections
While the precise cause of C. auris illnesses is uncertain, it is believed that healthcare workers can contract the illness by touching infected objects or surfaces.16 Patients in intensive care units are particularly susceptible to getting infected due to their reduced immunity and the invasive medical treatments they must endure.15 Misusing antibiotics can foster a situation where Candida can flourish and develop treatment resistance. Cancer, diabetes, and HIV/AIDS are among additional indicators of risk for C. auris outbreaks. Patients who were given bone marrow or organ transplants are also more susceptible to infection. Patients in intensive care units are at high risk for infections related to healthcare, especially those connected to intensive medical treatments. Various additional professional concerns arise while thinking about C. auris illnesses.

Healthcare Environment: C. auris outbreaks can propagate more quickly in healthcare. Equipment, polluted surfaces, and medical gadgets can all act as fungal reservoirs. To avoid transmission, good hygiene practices, such as routine sanitation and disinfection processes, are essential.16

Practices of Healthcare Workers: Medical professionals, nurses, and various other staff members all contribute significantly to preventing the transmission of C. auris infestations. Utilizing hand hygiene techniques like thorough hand washing or hand sanitizers that contain alcohol can significantly reduce the spread of fungi.17 In addition, medical personnel should adhere to the proper guidelines for handling and maintenance of obtrusive equipment to lower the possibility of infection.18

C. auris possesses a tendency to develop antifungal medication resistance, which would make therapy more challenging.19 Abuse or overuse of antifungal medications, especially in ICU circumstances, might result in an outbreak of drug-resistant strains.20 Medical professionals need to practice excellent antimicrobial administration to deal with this, which involves utilizing antifungal medications cautiously and by recommended treatment guidelines.21

Medical professionals need to practice excellent antimicrobial administration to address this, which includes taking antifungal medications cautiously and by recommended treatment norms. Diagnostic Difficulties: It can be challenging to distinguish C. auris infections due to its resemblance to other species of Candida and the limitations of conventional diagnostic testing. Healthcare professionals need to be knowledgeable about their clinical appearance, risk factors, and appropriate diagnostic techniques to accurately identify and manage these infections.22

Multidisciplinary Strategy: To effectively treat C. auris outbreaks in ICU patients, infectious disease specialists, microbiologists as well chemical scientists, and other physicians must work together. For the purpose of making an accurate diagnosis, choosing the best course of treatment, and keeping track of a patient’s response to therapy, cross-disciplinary collaboration is essential.23

Comprehensive infection prevention and control techniques must be employed to lower the incidence of C. auris infections. The use of personal protective equipment, stringent hand hygiene standards, routine fungal infection surveillance, and extensive disinfection and cleaning of healthcare facilities are all part of this.16

Training and Education: It is crucial to provide healthcare workers with ongoing instruction in infection control, the proper use of antifungal medications, and the early identification of C. auris infections. By staying up to date with the most recent research and recommendations, healthcare professionals can enhance their understanding of risk factors, prevention measures, and treatment options for these illnesses.24

In conclusion, medical staff who perform in ICU settings need to have a solid understanding of the risk factors, modes of transmission, diagnostic challenges, and available prevention measures for C. auris outbreaks. By focusing on infection control procedures, cautious antifungal medication use, and interdisciplinary collaboration, healthcare providers can successfully manage and reduce the impact of C. auris outbreaks on terminally sick patients.

Symptoms of C. auris infections
According to the type and degree of the infection, different C. auris infections will present with different symptoms. Frequent signs involve fever, chills, and exhaustion. Additionally, patients may develop oral thrush, nail infections, or skin rashes. A serious infection with C. auris can fail the organs, septic shock, and ultimately death.25

Given that their symptoms often resemble those of other diseases, C. auris lesions can be difficult to diagnose. To verify the diagnosis, a blood test is frequently required. A place of injury or other contaminated location may also be used for culture. To avoid difficulties and lessen the chance of infecting other patients, it is critical to recognize and address C. auris infections as soon as possible.25

Diagnosis and treatment of C. auris infections
Antifungal medicines are often used to treat C. auris infections. However, the number of antibiotic-resistant microbes means that there are fewer and fewer therapeutic choices available. To completely get rid of the infection, one may occasionally take an array of antifungal medications. It is crucial to constantly evaluate patients for pharmaceutical side effects and modify treatment as appropriate.26

Individuals having C. auris infestations require assistance with treatment in addition to medicines, such as feeding and water. To treat severe infections, patients might need to be hospitalized and receive intensive care. Surgery might be required in some circumstances to remove contaminated tissues or medical implants.27

Prevention of C. auris infections in the ICU
An all-encompassing strategy is necessary for avoiding C. auris outbreaks in the ICU. The use of personal protective equipment surface washing and disinfection, are required for preventing infections by healthcare providers. To stop the emergence of Candida strains that are resistant to antifungal, the abuse of antibiotics has to be tackled.28

Additionally crucial to avoiding infections are healthcare providers’ training and education for use of disinfectants used for C. auris (Table) Patients need to be informed about the dangers of intrusive medical treatments and the value of good cleanliness. The most recent treatments for C. auris outbreaks must be taught to healthcare professionals through continual training and continuing education.29

Table:
Surface disinfectants tested against C. auris16

Disinfectant
Concen. tested (contact time in minutes)
Effective
Level of evidence
Chlorine
0.39% (1), 0.65% (1), 0.825% (1), 1% (10), 2% (10), 1000 ppm (3, 5, 180, 1800), 10000 ppm (3, 180, 1800)
Yes
Good
Hydrogen peroxide
8 g/m3, 1.4% (1)
Yes
Moderate
Hydrogen peroxide+silver nitrate
11% (60)
Yes
Low
Phenolics
5%
Yes
Low
Glutaraldehyde
2% (20)
Yes
Low
Alcohols
29.4% (0.5)
Yes
Low
Acetic acid
>5% (3)
No
Low
Peracetic acid
2000 ppm (5, 10)
Yes
Low
Peracetic acid+hydrogen peroxide+acetic acid
1200 ppm/<1% (3)
Yes
Low
Quaternary ammonium compounds
2% didecyldimethyl ammonium chloride (60), alkyl dimethyl ammonium chlorides (10),didecyldimethyl ammonium chloride/dimethylbenzyl ammonium chloride (10)
No
Low

C. auris outbreak investigation
To find the root of the illness and stop it from spreading further, an in-depth investigation is required whenever a C. auris epidemic arises in the ICU. This inquiry may entail examining medical documentation and protocols for infection control as well as screening individuals and medical staff whether an outbreak of C. auris. To stop further transmission, it could be required to put outbreak control measures into place, including cohorting patients and stepping up the disinfection and cleaning procedures.30

The Impact of C. auris on ICU Patients
Patients in the intensive care unit are more susceptible to C. auris infections due to their weak immune systems. In addition to medical symptoms, patients may also experience emotional disturbances and disturbed life quality. Additionally, there is a possibility for negative outcomes which could lead to prolonged hospital stays and a great risk of fatality.31

The expenses of  C. auris outbreak treatment is very significant for both patients and healthcare facilities. The rising prevalence of antibiotic-resistant bacteria could result in higher medical expenses and a low ability to treat infections successfully as the hospital stays and intensive care are expensive.32

Future outlook and research
The growing frequency of C. auris breakouts in ICU patients is causing major problems for health care professionals. Due to the increase in antibiotic-resistant strains and the absence of effective treatments, infection prevention, and control are of the highest importance. The ongoing research is of utmost importance to identify novel treatments and defenses against C. auris epidemics.33

The rapid detection and treatment of C. auris diseases can be facilitated by the development of rapid diagnostic techniques. The possibility of antibiotic resistance and the spread of C. auris infections can be reduced through antimicrobial stewardship programs and other infection management techniques.30,34

CONCLUSION

Healthcare professionals must be knowledgeable about the causes, symptoms, and treatments of the C. auris outbreak to effectively combat it. A multifaceted strategy becomes the need of an hour to avoid infection in the ICU, including measures to prevent infection, patient and healthcare worker education, and ongoing investigations for new treatments and preventive measures. It becomes our prime duty to inform the healthcare providers of the recent research to safeguard the patients and stop the spread of C. auris infections.

Declarations

ACKNOWLEDGMENTS
None.

CONFLICT OF INTEREST
The authors declare that there is no conflict of interest.

AUTHORS’ CONTRIBUTION
All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.

FUNDING
None.

DATA AVAILABILITY
All datasets generated or analyzed during this study are included in the manuscript.

ETHICS STATEMENT
Not applicable.

References
  1. Brown GD, Denning DW, Gow NAR, Levitz SM, Netea MG, White TC. Hidden Killers: Human Fungal Infections. Sci Transl Med. 2012;4(165):165v13.
    Crossref
  2. Wisplinghoff H, Bischoff T, Tallent SM, Seifert H, Wenzel RP, Edmond MB. Nosocomial Bloodstream Infections in US Hospitals: Analysis of 24,179 Cases from a Prospective Nationwide Surveillance Study. Clin Infect Dis. 2004;39(3):309-317.
    Crossref
  3. Bajwa S, Kulshrestha A. Fungal infections in intensive care unit: Challenges in diagnosis and management. Ann Med Health Sci Res. 2013;3(2):238-244.
    Crossref
  4. Brown JS, Wessells H, Chancellor MB, et al. Urologic Complications of Diabetes. Diabetes Care. 2005;28(1):177-185.
    Crossref
  5. Pfaller MA, Diekema DJ. Epidemiology of Invasive Mycoses in North America. Crit Rev Microbiol. 2010;36(1):1-53.
    Crossref
  6. Chakrabarti A, Singh K, Narang A, et al. Outbreak of Pichia anomala Infection in the Pediatric Service of a Tertiary-Care Center in Northern India. J Clin Microbiol. 2001;39(5):1702-1706.
    Crossref
  7. Sharma BS, Khosla VK, Kak VK, et al. Intracranial fungal granuloma. Surg Neurol. 1997;47(5):489-497.
    Crossref
  8. Chakrabarti A, Das A, Sharma A, et al. Ten Years’ Experience in Zygomycosis at a Tertiary Care Centre in India. J Infect. 2001;42(4):261-266.
    Crossref
  9. Mayer FL, Wilson D, Hube B. Candida albicans pathogenicity mechanisms. Virulence. 2013;4(2):119-128.
    Crossref
  10. Mora C, Tittensor DP, Adl S, Simpson AGB, Worm B. How Many Species Are There on Earth and in the Ocean? Mace GM, editor. PLoS Biol. 2011;9(8):e1001127.
    Crossref
  11. Lockhart SR, Etienne KA, Vallabhaneni S, et al. Simultaneous Emergence of Multidrug-Resistant Candida auris on 3 Continents Confirmed by Whole-Genome Sequencing and Epidemiological Analyses. Clin Infect Dis. 2017;64(2):134-140.
    Crossref
  12. Osei Sekyere J. Candida auris : A systematic review and meta-analysis of current updates on an emerging multidrug-resistant pathogen. MicrobiologyOpen. 2018;7(4):e00578.
    Crossref
  13. Durbin RP. Letter: Acid secretion by gastric mucous membrane. Am J Physiol. 1975;229(6):1726.
    Crossref
  14. Watkins RR, Gowen R, Lionakis M, Ghannoum M. Update on the Pathogenesis, Virulence, and Treatment of Candida auris. Pathog Immun. 2022;7(2):46-65.
    Crossref
  15. Du H, Bing J, Hu T, Ennis CL, Nobile CJ, Huang G. Candida auris: Epidemiology, biology, antifungal resistance, and virulence. Xue C, editor. PLOS Pathog. 2020;16(10):e1008921.
    Crossref
  16. Ku TSN, Walraven CJ, Lee SA. Candida auris: Disinfectants and Implications for Infection Control. Front Microbiol. 2018;9:726.
    Crossref
  17. Abdolrasouli A, Armstrong-James D, Ryan L, Schelenz S. In vitro efficacy of disinfectants utilised for skin decolonisation and environmental decontamination during a hospital outbreak with Candida auris. Mycoses. 2017;60(11):758-763.
    Crossref
  18. Al-Rawahi GN, Roscoe DL. Ten-Year Review of Candidemia in a Canadian Tertiary Care Centre: Predominance of Non- albicans Candida Species. Can J Infect Dis Med Microbiol. 2013;24(3):e65-e68.
    Crossref
  19. Andes DR, Safdar N, Baddley JW, et al. The epidemiology and outcomes of invasive Candida infections among organ transplant recipients in the United States: results of the Transplant-Associated Infection Surveillance Network (TRANSNET). Transpl Infect Dis. 2016;18(6):921-931.
    Crossref
  20. Munoz JF, Gade L, Chow NA, et al. Genomic insights into multidrug-resistance, mating and virulence in Candida auris and related emerging species. Nat Commun. 2018;9(1):5346.
    Crossref
  21. Sabino R, Verissimo C, Pereira AA, Antunes F. Candida Auris, An Agent of Hospital-Associated Outbreaks: Which Challenging Issues Do We Need to Have in Mind? Microorganisms. 2020;8(2):181.
    Crossref
  22. Jeffery-Smith A, Taori SK, Schelenz S, et al. Candida auris: a Review of the Literature. Clin Microbiol Rev. 2018;31(1):e00029-17.
    Crossref
  23. Tsay S, Kallen A, Jackson BR, Chiller TM, Vallabhaneni S. Approach to the Investigation and Management of Patients With Candida auris, an Emerging Multidrug-Resistant Yeast. Clin Infect Dis. 2018;66(2):306-311.
    Crossref
  24. Caceres DH, Forsberg K, Welsh RM, et al. Candida auris: A Review of Recommendations for Detection and Control in Healthcare Settings. J Fungi. 2019;5(4):111.
    Crossref
  25. Cortegiani A, Misseri G, Fasciana T, Giammanco A, Giarratano A, Chowdhary A. Epidemiology, clinical characteristics, resistance, and treatment of infections by Candida auris. J Intensive Care. 2018;6:69.
    Crossref
  26. Murphy SE, Bicanic T. Drug Resistance and Novel Therapeutic Approaches in Invasive Candidiasis. Front Cell Infect Microbiol. 2021;11:759408.
    Crossref
  27. Pappas PG, Kauffman CA, Andes DR, et al. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2016;62(4):e1-50.
    Crossref
  28. Etienne KA, Roe CC, Smith RM, et al. Whole-Genome Sequencing to Determine Origin of Multinational Outbreak of Sarocladium kiliense Bloodstream Infections. Emerg Infect Dis. 2016;22(3):476-481.
    Crossref
  29. Collins AS. Preventing Health Care-Associated Infections. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008. (Advances in Patient Safety). http://www.ncbi.nlm.nih.gov/books/NBK2683/
  30. Infection Prevention and Control for Candida auris. Candida auris; Fungal Diseases. CDC 2023. https://www.cdc.gov/fungal/Candida-auris/c-auris-infection-control.html
  31. Briano F, Magnasco L, Sepulcri C, et al. Candida auris Candidemia in Critically Ill, Colonized Patients: Cumulative Incidence and Risk Factors. Infect Dis Ther. 2022;11(3):1149-1160.
    Crossref
  32. Ventola CL. The Antibiotic Resistance Crisis. Pharm Ther. 2015;40(4):277-283.
  33. Najeeb H, Siddiqui SA, Anas Z, et al. The Menace of Candida auris Epidemic Amidst the COVID-19 Pandemic: A Systematic Review. Diseases. 2022;10(3):58.
    Crossref
  34. Infectious Diseases Society of America (IDSA). Combating Antimicrobial Resistance: Policy Recommendations to Save Lives. Clin Infect Dis. 2011;52(suppl_5):S397-428.
    Crossref

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